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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750068
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:18:50 PM

Document Has Been Signed on 08/23/2023 03:18 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:PEARBLOSSOM ELEMENTARY SCHOOLFACILITY NUMBER:
197750068
ADMINISTRATOR:LUNA, JESUSFACILITY TYPE:
850
ADDRESS:12828 EAST AVENUE WTELEPHONE:
(661) 944-6019
CITY:PEARBLOSSOMSTATE: CAZIP CODE:
93553
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 3DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Cesar Herrera DirectorTIME COMPLETED:
03:30 PM
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On 08/23/23, Licensing Program Analyst (LPA's) Andrew Alemoh & Evelyn Garcia met with the facility Director Cesar Herrera for the One Year Required inspection for the preschool license in accordance with the facility sketch. A tour of the facility was conducted. Upon arrival LPA observed 3 preschool children and 2 teachers on the premises, along with the Director. The hours of operation are 8:30AM - 11:30AM morning session, 12:30PM - 3:30PM afternoon session, Monday - Friday. Incidental Medical Services (IMS) were discussed.

Indoor/Children’s Area:
Child care center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean, cleaning compounds located in the janitor closet is made inaccessible, poisons locked, furniture/equipment is good condition, free of flies, other insects, rodents; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, each child has an individual permanent or portable storage space (cubby, individually labelled with name) for his/her clothing, and personal belongings ). There is a working telephone.

Trash cans for solid waste have tight fitting lids, drinking water is readily available indoors and outdoors (Drinking water is available inside the center in the form of filtered water to fill up each child's water bottle). All materials and surfaces are toxic free are inaccessible, no fireplace. There is a working Carbon monoxide detector, smoke detector and Fire Extinguisher (3A40BC).
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PEARBLOSSOM ELEMENTARY SCHOOL
FACILITY NUMBER: 197750068
VISIT DATE: 08/23/2023
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Staff/Personnel Records: Director (qualified) qualifications were verified, Designation of Responsibility observed, immunization's, TB clearance, health screening, criminal record statement, statement acknowledging suspected child abuse and mandated reporter were observed in file.

Facility Records: Roster, fire/disaster drill log last completed on 07/24/2023, CPR/First Aid, and mandated report training were reviewed. LPA's observed Mandated Reporter training's to be completed from vector solutions. Class hours for the certification in staff files were 30mins.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty. The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 394L), emergency disaster plan, earthquake preparedness checklist.

Documents Provided and or Discussed: Child records, mandated reporter

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. CPR/First Aid expires on 05/2024.

Electrical outlets are inaccessible, recalled and or prohibited toys or sleep/play equipment were observed on the premises. There are no window cords accessible to children.

Sign in and out sheets were reviewed. The parent board was reviewed and has all of the required forms posted. Fire/earthquake drills current. Roster current.

Restrooms: LPA's inspected and observed 4 toilets, 3 urinals and 4 sinks all in working order. LPA observed soap, toilet paper and paper towels readily available. Water temperature is appropriate. There is an isolation area for children who become ill while in care located near the front office, facility maintains a comfortable temperature at all times, first aid supplies (thermometer, bandages, scissors), sign in/out sheets (Electronically and manually) available and completed daily. No Smoking prohibited on the premises, daily inspection for illness, no prohibited child care items observed. Firearms/weapons are not allowed on premises. There is no body of water on the premises.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
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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: PEARBLOSSOM ELEMENTARY SCHOOL
FACILITY NUMBER: 197750068
VISIT DATE: 08/23/2023
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Napping: The program is a 3 1/2 hour program and per the director the children do not nap.

Outdoor: The facility has one playground area for the preschool children. Outside play area is completely fenced by a wall. Outdoor play equipment was inspected for health, safety, good repair and age appropriateness. There is rubber matting and concrete areas for active play. The area was observed to be free of debris, free from hazard, holes, broken items, debris, cushioning material underneath. No bodies of water were observed. There are areas for shade and rest. Preschool children have their own personal water bottles as well as disposable cups. LPA's observed a storage shed for outdoor play that is off-limits to day care children. Per teacher statements the elementary school children utilize the storage shed toys. Day care children have their own separate toys.

Teacher child ratios were observed and staff name recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.

Health Related Services: Medications inaccessible to children; all prescription and non-prescription medications have child’s name and are dated; written consent and instruction from child’s representative, a plan to document and report to child’s representative when medication is administered to a child; IMS plan on file (if applicable).

Children are inspected for illnesses (wellness policy) as they arrive. A review of medication policy indicated that prescription medication is administered only with parent's written permission (licensing medication form- LIC9221 - also used). LPA advised the Director must administer medication, and document the dosage, date and time onto a log. Medication can be brought and taken home by the parent daily. Medication will be properly labeled and stored in its original container.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
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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: PEARBLOSSOM ELEMENTARY SCHOOL
FACILITY NUMBER: 197750068
VISIT DATE: 08/23/2023
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This facility provides Incidental Medical Services – IMS.
LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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/childquanda.htm

Food Service: The facility currently does have a food program. Meals such as AM snack, PM snack and lunch is provided. LPA's inspected the kitchen where food is prepared and observed the food menu. The kitchen is off limits to preschool children. Cleaning supplies were stored in closet that is inaccessible to children.

Director advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

Director was reminded that all adults 18 and over, 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 Child Care Center. 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.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Director shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of child care center or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
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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: PEARBLOSSOM ELEMENTARY SCHOOL
FACILITY NUMBER: 197750068
VISIT DATE: 08/23/2023
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

The facility is being issued a three Type B citation due to the children records being incomplete including immunization's. As well as the mandated reporter training being a 30min.

LPA's observed the children records to be incomplete, and or missing immunization's. LPA's advised the facility director to complete the children records and send a copy to LPA Alemoh as soon as possible.


A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
No deficiency. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.

Exit interview conducted and report was reviewed with Director Cesar Herra. This report was read and provided to Director Cesar Herra, along with her appeal rights and Notice of Site Visit.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2023 03:18 PM - It Cannot Be Edited


Created By: Andrew Alemoh On 08/23/2023 at 02:44 PM
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: PEARBLOSSOM ELEMENTARY SCHOOL
FACILITY NUMBER: 197750068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, LPA observed the mandated reporter training in the staff files to be completed from the vector solutions vendor. The certificate class was an half hour class. Due to the incorrect Mandated Reporter training it does poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Per director the staff will redo the mandated reporter class if the certificate does not abide by the regulations.
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 children did not have immunization records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Per director the facility will send copies of the children immunization records to LPA Alemoh no later than the due 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:Mariela Ramon
LICENSING EVALUATOR NAME:Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2023 03:18 PM - It Cannot Be Edited


Created By: Andrew Alemoh On 08/23/2023 at 02:44 PM
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: PEARBLOSSOM ELEMENTARY SCHOOL
FACILITY NUMBER: 197750068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in child #1, and #2 are missing multiple children record forms: ID, HH, PR, LIC613A,LIC627, LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Per Director he will send copies of children records to LPA Alemoh no later than the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
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:Mariela Ramon
LICENSING EVALUATOR NAME:Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


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