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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197701010
Report Date: 09/26/2025
Date Signed: 09/26/2025 11:11:39 AM

Document Has Been Signed on 09/26/2025 11:11 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:CHAVEZ ANDINO FAMILY CHILD CAREFACILITY NUMBER:
197701010
ADMINISTRATOR/
DIRECTOR:		TATIANA CHAVEZ ANDINOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 818-1017
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
09/26/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Tatiana Chavez Andino, Applicant TIME VISIT/
INSPECTION COMPLETED:
11:17 AM
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On 09/26/2025, Licensing Program Analyst (LPA) Justeene Tamayo conducted a Pre-licensing Inspection with Applicant Tatiana Chavez Andino , who guided LPA on a tour of the facility. Applicant has 3 years of experience as a Lead Teacher at a center based program. Applicant's minor child was present and will count as ratio during today's prelicensing visit.

This is a one-story house with 3 bedrooms, 2 bathrooms, living room, family room, dining room, kitchen, laundry room, and garage. Family members residing in the home include 2 adults(Applicant and applicants mother) and 4 minor children. All adults have been fingerprint cleared and associated. There are no bodies of water on the premises.

The facility will operate Monday through Friday from 6:00AM-6:00PM and with a license capacity of 14 children. A Fire Clearance has been granted on 09/12/25. LPA went over the child care ratios for a large family home with applicant, and provided applicant a copy.

Main care will be provided in the family room near the front door entrance as well as bedroom #1 (sleeping room). Children will eat in the family room as identified on the facility sketch, and outside if weather permits. Per applicant, she will be utilizing a food program. Breakfast, lunch, snacks and dinner will be provided. The day care children will utilize the hallway bathroom on the left hand side in the hallway.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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: CHAVEZ ANDINO FAMILY CHILD CARE
FACILITY NUMBER: 197701010
VISIT DATE: 09/26/2025
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Children will use rear yard for outdoor play. The front yard, bedroom #2-3(safety door knobs), bathroom #2(located in master bedroom), laundry room (located in garage with key lock/safety door knob), and garage (key lock/safety door knob) are off limits to the day care children.

Facility has central air and heating, age appropriate toys and play equipment, working smoke detector and carbon monoxide detector.

LPA did not observe any hazardous items in the child care bathroom. LPA reminded applicant the children's bathroom must be free of shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover. LPA observed a clean, safe and operable toilet and faucet.

LPA observed a fully charged 2A10BC fire extinguisher during the inspection located in the kitchen area. Per applicant, no alcohol is present in the home. First aid kit is stored in the hallway closet. Medications are stored in hallway closet with safety latch.

Applicant made poisons and cleaning items inaccessible to children stored under kitchen sink with safety latch.

Kitchen: The following are inaccessible: Sharp items, such as knives are stored in a locked tool box on the kitchen counter unreachable to day care children in care. 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.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
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: CHAVEZ ANDINO FAMILY CHILD CARE
FACILITY NUMBER: 197701010
VISIT DATE: 09/26/2025
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LPA toured the backyard and observe it to be free of garden tools, poisonous plants, thorn trees cactus, or lawn mower inaccessible to children. The backyard is completely gated. LPA observed toys, turf, swing set/slide, and sand box for the day care children to utilize. The right side of the back of the property has a safety gate to prevent accessibility. LPA observed a shade for outdoor play. Per applicant, she plans to install cushioning on the shade poles to prevent bumping accidents. Applicant will send proof of picture of the shaded poles once completed no later than 10/03/25.

There are no bodies of water on the premises. On the left side of the outdoor area, there is a outdoor air conditioner that is fully covered by mesh covering. Both sides of the back of the home have fencing. During walk through, LPA noticed a gap on the back of the property wrought iron fence. Applicant will cover the gap to ensure it is inaccessible to day care children, and will send proof of picture to LPA Tamayo no later than 10/03/25.

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, LIC9227 Individual Sleeping Plan, Safe Sleep log, required postings, and list of CCLD forms required for child file each child in care (LIC 311D). Applicant stated currently does not have child care insurance. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: CHAVEZ ANDINO FAMILY CHILD CARE
FACILITY NUMBER: 197701010
VISIT DATE: 09/26/2025
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Applicant inform smoking is prohibited, applicant stated no one smokes in the home, 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. Per applicant no firearms are present in the home. Applicant was informed her cell phone shall be available and charged at all times during day-care hours.

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

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CHAVEZ ANDINO FAMILY CHILD CARE
FACILITY NUMBER: 197701010
VISIT DATE: 09/26/2025
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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 writing within 7 day of incident to the department. Applicant was 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

Advisory/Other: Applicant First Aid/CPR are current and expires 07/13/2027. Mandated reporter training is complete and expires on 08/14/2027. Preventative Health & Safety training is completed on 05/28/2025. Electrical outlets are inaccessible to children. Children will nap on cots in the main care area. Applicant is 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 applicant, 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.

Pending Licensure:

-Covering of small gap in back of wrought iron fence in the backyard to prevent accessibility.

-Cushioning on shaded poles in the backyard to prevent bumping accidents.

Exit interview conducted copy of this report was provided to applicant along with notice of site visit.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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