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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364813457
Report Date: 11/04/2025
Date Signed: 11/04/2025 04:23:34 PM

Document Has Been Signed on 11/04/2025 04:23 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:PSD-CRESTLINE HEAD STARTFACILITY NUMBER:
364813457
ADMINISTRATOR/
DIRECTOR:		DENISE GRECIANFACILITY TYPE:
850
ADDRESS:22836 FIR LANETELEPHONE:
(909) 338-1470
CITY:CRESTLINESTATE: CAZIP CODE:
92325
CAPACITY: 30TOTAL ENROLLED CHILDREN: 15CENSUS: 0DATE:
11/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:41 PM
MET WITH:Facility Representative, Kenia Flores MartinezTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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On November 4, 2025, Licensing Program Analyst (LPA) Zirbes conducted a case management deficiencies inspection to address additional information regarding PSD-Crestline Head Start. LPA met with facility representative, Kenia Flores Martinez. Present during today's inspection were zero preschool children.
On August 26, 2025, LPA reviewed the facility records. Per staff attendance records, staff 1 (S1), staff 2 (S2), staff 3 (S3), and staff 4 (S4) were on site at 08:30am when the children were dropped off for the school day. S1, S2, S3 and S4 personnel records did not contain evidence that S1, S2, S3 or S4 had completed training on pediatric cardiopulmonary resuscitation (CPR) and pediatric first aid. Two additional staff members arrived at the site at 09:30am, who had completed training on pediatric CPR and pediatric First Aid. LPA interviewed facility representative Flores- Martinez regarding the staff CPR/First Aid training. Facility Representative confirmed S1, S2, S3 and S4 did not complete the required CPR/First Aid training. Therefore, based on LPA record review and interviews, on August 20, 2025, from 08:30am to 09:30am, the Center did not have at least one staff person on site who was trained in First Aid/CPR. A type B citation was issued for regulation, 101216 (f) Personnel Requirements. Refer to the LIC 809D. In addition, on August 26, 2025, LPA requested the review S3 and S4 personnel files. Based on LPA reviewed the following documentation was missing from S3 and S4 files, educational background, training and/or experience, Past experience, including types of employment and former employers, LIC 9052, health screening, documentation of Tuberculosis test and required immunizations, documentation of either a criminal record clearance or a criminal record exemption. Per LIC 500, S3 and S4 start date with the Center was August 7, 2025. When questioned about the personnel records for S3 and S4, facility representative Flores Martinez stated S3 and S4 are employed by Rim of the World School District and work at the PSD site.
Report continued on page two
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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: PSD-CRESTLINE HEAD START
FACILITY NUMBER: 364813457
VISIT DATE: 11/04/2025
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Report continued from page one

Facility representative Flores Martinez confirmed S3 and S4 did not have complete personnel records on site during the inspection. The Center was unable to provide the personnel records when LPA was on site from 1:00pm -2:30pm. Therefore, based on LPA record review and interview, on August 26, 2025, the Center did not have complete personnel records for S3 and S4. A type B citation was issued for regulation, Personnel Records 101217 (a), refer to LIC 809D.


Notice of Site Visit was given and must remain posted for 30 days. An exit interview was conducted, where this report and appeal rights were reviewed with facility representative Kenia Flores Martinez.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2025 04:23 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 11/04/2025 at 03:35 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: PSD-CRESTLINE HEAD START
FACILITY NUMBER: 364813457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2025
Section Cited
CCR
101216(f)

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Personnel Requirements 101216 (f): At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children...This requirement was not met as evidenced by:
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Per facility representative, all teachers and the site supervisor have obtained CPR/First Aid training. The Center will ensure there is always one staff member on site who meets the CPR/First Aid requirement.
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Based on LPA record review and interview on August 20, 2025, from 08:30am to 09:30am, the Center did not have at least one staff person on site who was trained in First Aid/CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
11/11/2025
Section Cited
CCR101217(a)

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Personnel Records 101217 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidenced by:
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Per Facility Representative, the site will ensure complete personnel records for staff and volunteers are on site prior to starting.
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Based on LPA record review and interview, on 8.26.25, the Licensee did not ensure personnel records for employees, S3 and S4 contained the required information, which poses/posed a potential health, safety or personal rights risk to persons 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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Kendal Zirbes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
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