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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197700306
Report Date: 08/26/2024
Date Signed: 09/05/2024 09:15:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Annelise Villa
PUBLIC
COMPLAINT CONTROL NUMBER: 12-CC-20240405151237
FACILITY NAME:SMITH FAMILY CHILD CAREFACILITY NUMBER:
197700306
ADMINISTRATOR:SMITH, CARLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 208-7582
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:14CENSUS: 2DATE:
08/26/2024
UNANNOUNCEDTIME BEGAN:
04:08 PM
MET WITH:Carla Smith, LicenseeTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Reporting Requirements - Licensee failed to report unusual incident to CCLD.
INVESTIGATION FINDINGS:
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On 9/5/2024, LPA Villa amended report to reflect Licensee's signature on file. On 8/26/24, Licensing Program Analyst (LPA) Annelise Villa concluded a complaint investigation at the Smith Family Child Care Home and met with the Licensee, Carla Smith. During today’s visit, LPA observed 3 children in care with the licensee caring for them.
The purpose of the inspection is to deliver complaint investigation findings. Investigation revealed an incident involving Licensee and a non-daycare child occurred on 4/3/2024, at the facility which resulted in police presence. Investigation revealed Licensee failed to report unusual incident to the Palmdale RO via phone within 24 hours and did not provide a written report within 7 calendar days in accordance with Title 22, Section 102416.2. Based on the interviews and documentation gathered, there is a preponderance of the evidence to prove this is substantiated. A finding that allegations are substantiated means the allegation happened or is valid, and there is a preponderance of evidence to prove the alleged occurred. A Type B deficiency was cited.
A copy of the report was given to the licensee along with appeal rights and a notice of site visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 12-CC-20240405151237
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 197700306
VISIT DATE: 08/26/2024
NARRATIVE
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See LIC 9099 for report
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 12-CC-20240405151237
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 197700306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2024
Section Cited
CCR
102416.2
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102416.2 (a) Reporting Requirements. The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). This requirement was not met as evidenced by:
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Licensee will a submit unusual incident report for the altercation that occurred on 4/3/24 and submit unusual incident reports for all future incidents.
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Based on record review and interviews, revealed an incident occured on 4/3/24, wherein police were present at the home with daycare children present. No unusual incident report was received, which poses a potential health, safety, and personal rights risk of 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.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3