197700994-8-8-2025-12-CC-JTAO-DKCP9Y-20250808110754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197700994
Report Date: 08/08/2025
Date Signed: 08/08/2025 11:08:07 AM

Document Has Been Signed on 08/08/2025 11:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	FLORES DE RAFAEL FAMILY CHILD CARE		FACILITY NUMBER:	197700994
ADMINISTRATOR/ DIRECTOR:	MARTA FLORES DE RAFAEL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 979-6205
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	08/08/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:06 AM
MET WITH:	Marta Flores De Rafael, Applicant		TIME VISIT/ INSPECTION COMPLETED:	11:17 AM

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On 08/08/2025, Licensing Program Analyst (LPA) Justeene Tamayo conducted a Pre-licensing Inspection with Applicant Marta Flores De Rafael who guided LPA on a tour of the facility.

This is a two-story home with 4 bedrooms, 3 bathrooms, living room, family room, dining room area, kitchen, garage, front yard, and backyard. Family members residing in the home include 3 adults (Applicant, applicant's spouse, and applicants adult daughter) and 0 minor child. All adults have been fingerprint cleared and associated. There is an above ground jacuzzi in off-limits backyard area.

The facility will operate Monday through Friday 5AM-6PM, and with a license capacity of 14 children. Fire clearance has been granted effective 07/28/2025. LPA went over the child care ratios for a large family home with applicant, and provided applicant a copy. This is a relocation application (prior license number #198020186)

Main care will be provided in the family room near the kitchen area. Children will be eating in the family room(main care area). The day care children will utilize the bathroom located in the main care area(family room). The entire family room is barricaded by two safety gates (one leading to the family room, and one leading to the kitchen area).

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FLORES DE RAFAEL FAMILY CHILD CARE	FACILITY NUMBER: 197700994
	VISIT DATE: 08/08/2025

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The front yard, living room (barricaded by safety gate), bedrooms #1-4(entire upstairs barricaded by safety gate), bathrooms #2-3(located upstairs barricaded by safety gate), kitchen(barricaded by safety gate), laundry room located in garage(safety door knob), and garage(safety door knob) are off limits to the day care children. Per applicant, there are no firearms or animals on the premises.

LPA observed day care area to be clean and orderly, central air and heating, age appropriate toys and play equipment were observed. Smoke and carbon monoxide detector was tested and in operable condition.

LPA observed a clean, safe and operable toilet and faucet. The child care bathroom is located on the first floor in the main care area (family room). LPA reminded applicant the children's bathroom must be free of shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover.

LPA observe a fully charge 2A10BC fire extinguisher during the inspection located in the family room. LPA reminded applicant, fire extinguisher must be serviced annually and read in green. First aid kit is stored in the the family room.

Applicant made poisons and cleaning items inaccessible to children stored under the kitchen sink with a safety latch. Medications are also stored in the off-limits master bedroom upstairs.

Kitchen: LPA observed the kitchen area to be free of hazards. Kitchen is fully barricaded by a safety gate. The following are inaccessible: Sharp items are stored in the kitchen drawer with a safety latch. LPA observed the refrigerator and freezer to be clean. LPA discuss with applicant food shall be properly stored or refrigerated in container that are labeled with child’s name when supplied by parent. Per applicant, she plans to have a food program. Breakfast, lunch, AM snack, and PM snack will be provided.

Outdoor: The children will be utilizing a portion of the backyard for outdoor play. The children's outdoor play area is fully barricaded by white picket fencing to ensure children are unable to have access to the rest of the off-limit areas in the backyard. There is an outdoor air conditioner fully barricaded by white picket fencing. There is outdoor play equipment, jungle gym, and basketball hoop that will be utilized. There is cement and turf for outdoor play.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FLORES DE RAFAEL FAMILY CHILD CARE	FACILITY NUMBER: 197700994
	VISIT DATE: 08/08/2025

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Applicant also installed a metal patio cover for shade while the children utilize the backyard for outdoor play.

In the off-limits backyard area, there is an above ground jacuzzi under a tan gazebo. The jacuzzi is secured on all sides/locked and covered. LPA observed a total of 4 side release buckle locks, and the jacuzzi cover is able to withstand the weight of an adult following Title 22 regulations.

There is also a water fountain near the back of the cement wall in off-limits backyard that is fully empty. LPA reminded applicant, the water fountain must remain empty at all times. The left side of the backyard also has a brick pizza oven that is off limits by the white picket fencing to ensure children do not have access.

Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Documents Provided and or Discussed: The following were provided to comply with Title 22 requirements: Fire Drill Log, roster, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan (LIC9227), Safe Sleep Log, water lead poster, required postings and list of CCLD forms required for child file each child in care (LIC 311D). Applicant stated currently does not have childcare insurance. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

Applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in wring within 7 day of incident to the department. Applicants were informed all suspected Child Abuse should be reported to the Child Abuse Hot-line at 1-800-540-4000. The above incident should be reported on the form LIC624B per the regulation. The form should be email to unusualincidentreport@dss.ca.gov

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FLORES DE RAFAEL FAMILY CHILD CARE	FACILITY NUMBER: 197700994
	VISIT DATE: 08/08/2025

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Advisory/Other: LPA observed a first Aid kit with emergency supplies and a thermometer in the main care area(family room). Applicant First Aid/CPR are current and expires 12/21/2026. Preventative Health & Safety training is completed on 05/22/2025. Mandated Reporter training expires on 03/12/2026 and can be renewed every 2 years at www.mandatedreporterca.com. Electrical outlets are inaccessible to children. Children will nap on mats in the main care area. Applicant aware no infant shall be swaddled, and car seat shall not be used for sleeping. Applicant is aware to supervise infants while they are sleeping by physically checking every 15 minutes and documenting the infant’s status. Applicant should refer to regulation 102425(J) for documentation requirement. If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, the provider shall return the infant to their back for sleeping.

LPA discussed the safe sleep regulations with applicants, including Safe Sleep PIN 20-24-CCP and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Applicant informed smoking is prohibited. LPA discussed Health Section 1596.846(b) and (c)–102417 (g)(10) and provided applicant with a visual copy of prohibited items. LPA did not observe prohibited items during the inspection.

Applicant was informed their cell phone shall be available and charged at all times during daycare hours.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: FLORES DE RAFAEL FAMILY CHILD CARE	FACILITY NUMBER: 197700994
	VISIT DATE: 08/08/2025

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Incidental Medical Services (IMS) policy was discussed, informing applicant when any IMS is provided, a plan for providing IMS must be submitted to the Department prior to providing care to a child that need IMS. The plan shall state the type of IMS the facility will be offering, stating the person providing care has been trained to provide the named IMS. The plan will also provide the steps that will be taken when IMS is provided to a child.

The following information regarding ADA was discuss and the following information 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

Applicant is ready for licensure.

Exit interview conducted copy of this report was provided to applicant, along with a Notice of Site Visit.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

LIC809 (FAS) - (06/04)

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