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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700097
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:19:29 PM

Document Has Been Signed on 02/14/2024 12:19 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:RAMIREZ FAMILY CHILD CAREFACILITY NUMBER:
197700097
ADMINISTRATOR:RAMIREZ, RAQUELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 605-0539
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Raquel Ramirez, LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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On February 14, 2024, Licensing Program Analyst (LPA’s) Calloway and Braddock met with Licensee, who granted access. LPA’s and Licensee toured the home inside and outside for an Annual Random inspection. Residing in the home are the Licensee, spouse, two adult daughter, and two minor children. The home is licensed for twelve to fourteen children. LPAs observed seven (7) children in active care with licensee during inspection.
Physical Plant: This is a single story 3-bedroom, 2-bathroom home with kitchen, dining room, living room, and garage. Childcare is provided: in Garage (next to the kitchen). Children’s Bathroom: is in hallway on the right (observed- with chemicals). Unused outlets (covered). Blinds (vertical). Age-appropriate toys, furniture, and books (observed). Napping equipment (cots). The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (laundry area- locked), medicines (kitchen cabinet-up high). Surveillance camera (operable).
Kitchen: (accessible) hazardous items that can pose a danger to children (sharp knives in lower drawer with safety latch). LPA recommended knives to be moved to upper cabinet with safety latch. Licensee will buy gate to make kitchen inaccessible. Fire/earthquake drills (not current). Roster (not current). The required fire extinguisher (2A10BC) (full/green). Smoke detectors and carbon monoxide detectors (operable). Fireplace is screened.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097
VISIT DATE: 02/14/2024
NARRATIVE
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Home has central AC and heat. Required postings were not present on the wall. No landline phone, but cell phone. Fire alarm pull (observed).
Off limit areas: Bedrooms: #1, #2, #3 (key-lock), Kitchen, Bathrooms: #2, and laundry (in garage-locked).
Outside: The backyard is completely fenced. Pets: two dogs (vaccinated). Per Licensee, the pets do not interact with the day care children. There are eleven (11) chickens (gated). Swing/slide set (anchored) and play apparatus. There is concrete and sand for play and a shaded area. No pool/spa or body of water on the premises. AC unit (covered- around).
Others: Per Licensee, there are no weapons or firearms on the premises. LPA did not observe any in the home. Required mandated reporter training (not current), CPR/First Aid (Exp: 12/25) and immunizations (current). First Aid kit (observed). LPA viewed staff and children’s files and reviewed all infants in care do not have LIC 9227 form in their files. LPA conducted a staff interview with the licensee. Transportation is provided (insurance verified). Incidental Medical Services (IMS) policy and Safe Sleep regulations were discussed.The following was discussed with the Licensee:
Maintain capacity and transparency per posted parent rights, Roster requirements (keep updated information always), Documentation for disaster drills (fire and earthquake). Mandatory forms, signed, for the children’s files and provider’s files, updated Safe Sleep regulations. The role and responsibilities of being a mandated reporter were reviewed. Licensee reminded that supervision is always required to children in care. If food is brought in, it is properly labeled. Licensee will check food expiration dates periodically. Licensee was advised on how to access forms and regulations for Family Child Care online at www.ccld.ca.gov.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097
VISIT DATE: 02/14/2024
NARRATIVE
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Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care and temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. If closed for the day, (no kids), or absent notify Licensing. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified. Regulations prohibit the smoking of tobacco in a private residence that is licensed as a family childcare home and areas of the day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.Type A deficiency: Type A deficiency shall be posted for 30 consecutive days along with the Notice of Site Visit Letter (printed out after every visit) and posted during hours of operation, as there is an immediate risk to the health, safety, or personal rights of children in care. Licensee shall provide a copy any Type A deficiency to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of the Type A report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in the child's file for verification of the Type A deficiency. Failure to do so will result in a civil penalty being assessed.
Licensee is advised to visit: www.shotsforschool.org for Immunization information.
--Licensee was informed of their responsibility to report suspected Child Abuse (LIC 9108), 1-800-827-8724/760-243-6640
--Family Child Care Providers (Disaster Planning information):
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097
VISIT DATE: 02/14/2024
NARRATIVE
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https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Child Care Videos: https://ccld.childcarevideos.org
--Licensee advised to visit the CCLD website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department prior to providing the IMS. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.
Lead Poisoning: For more information, go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600. Reminder: The On Duty Worker is available for questions at: (661) 202-3318 (Monday-Friday 8am-5pm) and for reporting Unusual Incident Reports (within 24 hours). Written Unusual Incident Reports are sent (using (LIC 624B form) to the following email address: unusualincidentreport@dss.ca.gov within seven (7) days after reporting the incident via telephone. Per Title 22 Regulations, Division 12, Chapter 1, there are deficiencies cited during this inspection. See 809D pages attached to this report.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit, Appeal Rights were provided to S1, Licensee. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting will result in $100 civil penalty.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation,interview, the licensee did not comply with the section cited above LPAa observed soaps, shampoos, inside the children's bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee will provide proof of correction by POC date.
Type A
Section Cited
CCR
102425(j)(2)(C)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Infants up to 12 month of age who are sleeping in a position other than on their back.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review the licensee did not comply with the section cited above C1 was observed sleeping on their stomach in playpen with a blanket which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee will provide written declaration as to how to correct this and provide proof to Licensing by POC date
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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation interview record review, the licensee did not comply with the section cited above did not have noted LIC 610 for view which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Licensee will correct by POC date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, record review, the licensee did not comply with the section cited above in completing drills every six months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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2
3
4
Licensee will provide proof by POC date

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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in C1 did not have an infant log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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2
3
4
Licensee will provide proof by POC date
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation interview record review, the licensee did not comply with the section cited above in mandated reporter training is expired for Licensee and assistant which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
1
2
3
4
Licensee will provide proof by POC date
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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview, record review, the licensee did not comply with the section cited above in CPR for assistant expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
1
2
3
4
Licensee will provide proof by POC date
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in faciliyt roster was not updated which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
1
2
3
4
Licensee will have roster updated by POC date
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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in C1, C5, C6 did not have LIC 995 form in files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
1
2
3
4
Licensee will provide proof by POC date

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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 02/14/2024 12:19 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 02/14/2024 at 11:54 AM
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: RAMIREZ FAMILY CHILD CARE
FACILITY NUMBER: 197700097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation interview record review, the licensee did not comply with the section cited above in C1-C7 did not have LIC 282 form in files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
1
2
3
4
Licensee will provide proof by POC date
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in C1 did not have form in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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