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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 263801965
Report Date: 10/22/2025
Date Signed: 10/22/2025 01:27:26 PM

Document Has Been Signed on 10/22/2025 01:27 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MONO LEE VINING PRESCHOOLFACILITY NUMBER:
263801965
ADMINISTRATOR/
DIRECTOR:		TAMMY NGUYENFACILITY TYPE:
850
ADDRESS:296 MATTLYTELEPHONE:
(760) 647-6095
CITY:LEE VININGSTATE: CAZIP CODE:
93541
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 4DATE:
10/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:47 PM
MET WITH:Julia Vargas, TeacherTIME VISIT/
INSPECTION COMPLETED:
01:27 PM
NARRATIVE
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On 10/22/25, Licensing Program Analyst (LPA) Crystal Ali met with Teacher Julia Vargas to conduct an unannounced case management (CM) inspection. The purpose of the case management was to follow up on unusual incident report (UIR) received 9/10/25. Incident occurred on 9/10/25, C1 had a seizure during naptime. Teacher Vargas notified the parent and called 911. Parent arrived before paramedics and administered C1 medication. Paramedics transport C1 and parent to hospital. C1 returned to preschool on 9/16/25. C1 is on new medication starting 10/14/25.

Upon arrival, LPA observed 4 preschool children and 1 staff providing care and supervision.

During this inspection LPA conducted interview with teacher and C1. LPA obtained copy of LIC 500.

CM findings show that the facility followed CCR and HSC guidelines for UIR reporting incident and supervision. However, facility did not follow regulation CCR 101221 (b)(10)-record of current medications, including the name of the prescribing physician, and instructions, regarding control and custody of medications. Deficiency has been cited.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MONO LEE VINING PRESCHOOL
FACILITY NUMBER: 263801965
VISIT DATE: 10/22/2025
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A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted with Lead Teacher, Julia Vargas.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Crystal Ali
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2025 01:27 PM - It Cannot Be Edited


Created By: Crystal Ali On 10/22/2025 at 01:13 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: MONO LEE VINING PRESCHOOL
FACILITY NUMBER: 263801965

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2025
Section Cited
CCR
101221(b)(10)

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(10) Record of current medications, including the name of the prescribing physician, and instructions, ...regarding control and custody of medications.

This requirement was not met as evidence by:
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Facility representative states that she will obtain the correct documentation from the parent and send proof of completion to LPA Ali.
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Based on observation, interviews and record reviews the facility representative did not have the proper authorization from doctor and parent regarding current medication records in (from 10/14/25) child file during inspection, which poses an immediate risk to the health safety and personal rights of the clients
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.
Claretta Yates
NAME OF LICENSING PROGRAM MANAGER:
Crystal Ali
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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