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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416481
Report Date: 09/24/2025
Date Signed: 09/24/2025 04:19:52 PM

Document Has Been Signed on 09/24/2025 04:19 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:SHIRLEY FAMILY CHILD CAREFACILITY NUMBER:
197416481
ADMINISTRATOR/
DIRECTOR:		SHIRLEY, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 904-7211
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
09/24/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Jasmin Barila, AssistantTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On Wednesday, September 24, 2025, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with assistant Jasmine Barila who granted access and guided LPA Rivera on a tour of the facility. Upon arrival, licensee was not present.

Family members residing in the home have been discussed with assistant and are cleared. LPA observed two assistants, 2 infants (12-23 months) and 10 preschool children present. LPA observed facility to be within ratio and present staff are fingerprinted cleared and trained in pediatric first aid/CPR. Operating hours are Monday to Friday from 7:00 a.m. to 5:00 p.m. and care for children ages 0 to 5 years old.

This facility is a two-story home that consists of 4 bedrooms, 3 bathrooms, kitchen, living room, dining room, laundry room, and front and backyard.

Areas off limits to children include- All second floor (barricaded with installed safety gate), bedroom, and bathroom (in bedroom) located first floor near the entrance hallway, kitchen, laundry room, and pool area.
Areas accessible to children include- living room, dining room, bathroom located in the hallway and backyard.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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: SHIRLEY FAMILY CHILD CARE
FACILITY NUMBER: 197416481
VISIT DATE: 09/24/2025
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LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed central AC/heater, and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed a fireplace and observed a childproof lock on the screen. Per assistant, the fireplace has not been turned on and is off and requires a key to turn on. LPA did not observe play yard or cribs. LPA observe the sleeping mats to be in good condition.

LPA Rivera observed cleaning compounds items and knives sharp objects stored in the laundry room. LPA observed the door closed and locked with a key. For water drinking, LPA observed water filtered and sippy cups. The assistant stated the facility provides snacks and meals. LPA informed assistant any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Assistant stated currently does not have any children with severe food allergies and has one child with prescribed Albuterol. LPA observed Albuterol with expiration date 11/2025 and LIC 9221 Parent Consent for Administration of Medications.

LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded assistant and personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the assistant if there were any pets, poisons, firearms, weapons, or bodies of water. The assistant stated one dog and a turtle, poisons, and body of water. No firearms, and no weapons. LPA observed one dog, poisons in the laundry room, and in- ground pool in the backyard. LPA observed the pool area to have a mesh fence and does not cover all around and the bottom of the fence has no gap openings. To complete the full coverage, LPA observed a brick wall that is shared with side and back neighbors. There are no windows on the side of the brick walls (pool area). LPA measured the height of the mesh fence from the ground up to the top of the fence to be 5.0 ft high and fence does not obscure the pool from view. The openings of the railings, LPA measured and observed the openings to be 3 inches wide. LPA observed the door to swing away from the pool and the
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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: SHIRLEY FAMILY CHILD CARE
FACILITY NUMBER: 197416481
VISIT DATE: 09/24/2025
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self-latching device is no more than 6 inches from the top of the gate. LPA reminded assistant, the mesh fencing must not be removed and no ladders or any climbing equipment near the fencing. LPA informed assistant, if in the future the fencing needs to be replaced, licensee will need to contact the department to notify about the change. LPA observed and tested the water alarm and heard the sound. LPA observed a 24-inch life ring and approved by the United States Coast Guard and a rescue pole with a body hook with a fixed length of 15ft. LPA observed the daily inspection drowning prevention safety log.

LPA observed the poisons to be stored in the laundry room and the doorknob is locked. LPA reminded that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.

LPA Rivera observed the required 2A10BC fire extinguisher located in the dining room and the valve on the green area indicating fully charged. LPA observed purchased receipt dated 11/20/2023. LPA informed assistant fire extinguisher must be serviced annually or show purchased receipt within the year LPA observed carbon monoxide detector in the laundry room and smoke alarm located in the hallway. LPA tested the carbon monoxide and smoke alarm. LPA Rivera heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the daycare room top cabinet. For ill isolation, assistant stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on 6/9/25.

LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced, and side gates closed and with a self-latch. LPA observed the play equipment to be age appropriate and 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 observed e a mesh cover on the AC compressor. For outdoor water drinking, children bring out their water bottles.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: SHIRLEY FAMILY CHILD CARE
FACILITY NUMBER: 197416481
VISIT DATE: 09/24/2025
NARRATIVE
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LPA Rivera observed assistant Jasmine American Heart Association Pediatric First Aid/ CPR dated 9/4/25. and has proof of immunization against Pertussis, MMR, and Influenza declination. Assistant has completed the Child Abuse Mandated Reporter training dated 11/12/23.

LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, LIC 610A Emergency Disaster Plan, and Pub 394 Notification of Parents Rights. LPA also reviewed safe sleep logs, children’s roster, children, and staff files.

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 and appeal rights were reviewed with licensee Jasmine Barila.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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