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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405109
Report Date: 08/06/2025
Date Signed: 08/06/2025 05:49:17 PM

Document Has Been Signed on 08/06/2025 05:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:CONGREGATION BETH SHALOMFACILITY NUMBER:
197405109
ADMINISTRATOR/
DIRECTOR:		CAROL BLOOMFACILITY TYPE:
850
ADDRESS:21430 CENTRE POINTE PARKWAYTELEPHONE:
(661) 254-2411
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 96TOTAL ENROLLED CHILDREN: 96CENSUS: 10DATE:
08/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Carol Bloom, DirectorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On Wednesday, August 6, 2025, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with director Carol Bloom who granted access and guided LPA Rivera on a tour of the facility.

This is a preschool program that serves children ages 2 to 6 years. This program operates Monday to Friday 6:30 a.m. – 6:30 p.m. Sign in and out takes place at the entrance of the classrooms. All areas identified on the facility sketch were toured and inspected both indoors and outdoors. Teacher and child ratio were observed. Annual fee is current, and all staff are fingerprinted cleared and have American Heart Association Pediatric First Aid/ CPR dated 3/21/25.

LPA entered classrooms #3 and #4 (two-year-old) split. LPA Rivera observed 6 pre-school children with staff #1 and staff #2 present providing care and supervision. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside the top cabinet with a child proof lock, making it inaccessible for children to open. LPA Rivera observed a step trash bin with a lid. LPA observed cubbies for children to store their personal belongings.

LPA entered classrooms #7 and #8 (three-year-old) split. LPA Rivera observed 4 pre-school children with staff #3 and staff #4 present providing care and supervision. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside the top cabinet with a child proof lock, making it inaccessible for children to open. LPA Rivera observed a step trash bin with a lid. LPA observed cubbies for children to store their personal belongings.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 08/06/2025
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LPA entered classrooms #9 and #10 (pre k) split. LPA Rivera observed classroom unoccupied. Per director classrooms are utilized during school season and not during summer camp. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside the top cabinet with a child proof lock making it inaccessible for children to open. LPA Rivera observed a step trash bin with a lid. LPA observed cubbies for children to store their personal belongings.

Classrooms #5 and #6 currently not being utilized due to low enrollment. The classrooms are currently being utilized as a storage.

LPA Rivera observed boys and girl’s restrooms located in the hallway by director’s office. LPA observed a total of 8 toilets, 7 hand washing sinks, and two urinals. LPA observed the restrooms to be in good condition and free from hazards.

Heating, lighting and ventilation were evaluated by LPA Rivera. LPA observed central AC /heater and vents located on the ceiling. LPA observed the thermostat located in classroom 9 and the temperature to be at 78 degrees. Smoke detectors were not tested during this visit due to the detectors being wired to the emergency pull down fire alarm system. LPA observe carbon monoxide detector in the classrooms. LPA Rivera tested all and heard the sounds and are operable. The last emergency drill was conducted on 5/22/25.

LPA observed sleeping cots to be in good condition. First aid kits supplies are kept inside the classrooms and LPA observed the kits to be complete with band aids, gauzes, adhesive bandages, and antiseptic wipes. During this visit, director Carol stated child #1 has prescribed EPI PEN. LPA observed the EPI PEN to expire on 5/19/26 and located in the child’s classroom inside top cabinet in a clear bin and made inaccessible to children. LPA Rivera asked if there were any poisons, firearms, weapons, or bodies of water. The director stated there were no firearms, weapons, no poisons nor bodies of water. LPA did not observe firearms or weapons, poisons, nor bodies of water. Director

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 08/06/2025
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stated the ill isolation area takes place in the director’s office and children utilize the girls handicap stall. testing was conducted on 12/30/2022 and there was lead exceedance. February 2023, the faucets in the kitchen were replaced and re-tested on 6/20/25 and no lead exceedance. During 12/30/22 to 6/20/25, facility was using the filtered water fountain located in the hallway to refill water pitchers and rinse fruits and vegetables.

LPA Rivera entered the outdoor play area (garden area, play yard, and grass yard). LPA Rivera observed the playground to be fenced all around and the gates closed with keypad locks. LPA Rivera observed the equipment to be in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera observed play structure equipment to be age appropriate and areas around or under high climbing equipment, are cushioned with woodchips that may absorb a fall. For adequate shade, LPA Rivera observed 3 hip roof shade structures and 2 sail triangles. LPA observed step trash bin with a lid. LPA observed total of 3 sheds, one in the garden area and two in the play yard. LPA observed the sheds closed and locked with a padlock. For outdoor water drinking, staff bring out water pitchers and children sippy cups.

This program provides am and pm snacks. Meals are brought from children’s home. LPA Rivera informed director Carol that any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. For water drinking, LPA Rivera observed water pitchers, disposable cups and sippy cups in the classrooms. LPA observed the food preparation area to be clean and free of litter, rubbish, rodents, and/or any other vermin and storage containers for solid waste, including movable bins with tight-fitting covers that are kept on, and in good repair. The facility was observed to be free of flies, other insects and rodents. Lead testing was conducted on 12/30/2022 and there was lead exceedance. February 2023, the faucets in the kitchen were replaced and re-tested on 6/20/25 and no lead exceedance. During 12/30/22 to 6/20/25, facility was using the filtered water fountain located in the hallway to refill water pitchers and rinse fruits and vegetables.

The following documents were posted in a prominent, publicly area front lobby: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), Menu, and Daily Schedule.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 08/06/2025
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LPA Rivera reviewed the children’s roster, children’s files, staff files and observed 10 signed in signatures.

LPA Rivera observed director Carol Bloom American Heart Association Pediatric First Aid/CPR certification dated 3/21/25, Preventative Health and Safety dated 7/29/2001 and has proof of immunization against Pertussis, MMR and Influenza. Director has completed the child abuse mandated reporter training dated 6/2/2024. Director was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com


The following was also discussed with director:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Breakfast/Lunch/Snack Menus: Menus are required to be posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days must also be available upon request.

3. Current Children’s Roster: Each childcare facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

4.LIC 125 Entrance Checklist provided, and LPA informed that forms, regulations and quarterly updates can be accessed on the Child Care Licensing website at: www.ccld.ca.gov.

5.Pediatric First Aid and CPR: At least one person trained in Pediatric First Aid and CPR and EMSA approved must be present.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 08/06/2025
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6. Designated Staff: The name of the childcare center director or fully qualified teacher(s) designated to act in the director's absence must be on file.

7. Qualifications: Educational background, training, and/or experience for each staff present must be available for review.

8. Immunization Requirements: Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles or influenza declination

9. Children’s Records: must be available for review; including but not limited to, the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

Director Carol Bloom was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 08/06/2025
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Director Carol Bloom was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

No deficiencies given during this visit. A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview conducted and report was reviewed with director Carol Bloom.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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