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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412222
Report Date: 09/26/2023
Date Signed: 09/26/2023 05:11:51 PM

Document Has Been Signed on 09/26/2023 05:11 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:CABRERA FAMILY CHILD CAREFACILITY NUMBER:
197412222
ADMINISTRATOR:CABRERA, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 965-1080
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
09/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Guadalupe CabreraTIME COMPLETED:
05:30 PM
NARRATIVE
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On 9.26.23 Licensing Program Analyst (LPA) Kris Diaz met with the Licensee, Guadalupe Cabrera for a case management incident inspection involving an Unusual Incident Report (UIR) received 9/1/2023. Licensee granted access to the home and guided LPA on a tour. Upon arrival, there were 11 children and 2 staff present including the licensee.

Description of the incident: A incident occurred on 8/31/2023 at approximately 3:54 PM. The UIR was submitted by licensee and describes the incident as follows. S1 was in the backyard of the FCCH with C1, C2, and C3. C1 was climbing from the slide to the monkey bars. Per 624B, on C1s third time climbing from the slide to the monkey bars, C1 reached for a monkey bar that was farther away from the slide. C1 missed the monkey bar and fell to the ground. C1 screamed after C1 fell and C1 was holding their hand/wrist.

LPA conducted interviews with C1, C4, S1 and S2, viewed and recorded video (on state cellphone) of incident from licensees video monitor and reviewed records. Licensee stated she could not record the video on a usb. Interviews and video viewed revealed that S1 walked away from children and did not have visual observation of the children when C1s injury occurred.
Based on interviews, observations, and record review it is determined that the staff failed to provide sufficient care and supervision including visual observation as outlined in the regulation resulting in a serious injury of C1. Therefore, this facility is being cited for a Type A deficiency and an immediate civil penalty of $500 will be assessed on this date.



See Facility Evaluation Report LIC 809D for deficiency.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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Document Has Been Signed on 09/26/2023 05:11 PM - It Cannot Be Edited


Created By: Kristina Diaz On 09/26/2023 at 04:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: CABRERA FAMILY CHILD CARE
FACILITY NUMBER: 197412222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/26/2023
Section Cited
CCR
102417(a)

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102417 (a) Operation of a Family Child Care Home
The licensee shall be present in the home and shall ensure that children in care are supervised at all times.

This was not met as evidence by:
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When children outside need assistance licensees assistants will inform her of their needs and she will come to aid them so children are supervised at all times.
https://ccld.childcarevideos.org/family-child-care-providers/supervising-children-in-family-child-care/
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Based on observation, record review and
interview staff supervising children outside walked away from children and did not have visual observation of the children resulting in child falling and seriously injuring wrist.

cont'd in adjacent column
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This poses an immediate Health, Safety, and Personal Rights risk to the children in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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