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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364818001
Report Date: 03/15/2023
Date Signed: 06/06/2023 04:54:43 PM

Document Has Been Signed on 06/06/2023 04:54 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:NELSON FAMILY CHILD CAREFACILITY NUMBER:
364818001
ADMINISTRATOR:NELSON, LILLIAN & EARLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
7609515002
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/15/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lillian NelsonTIME COMPLETED:
03:15 PM
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On 3.15.23, Licensing Program Analyst (LPA) Kris Diaz and Licensing Program Manager (LPM) Claretta Yates, conducted an unannounced Annual inspection. LPA/LPM met with Licensees, Earl and Lillian Nelson who guided LPA/LPM on a tour of the home. People who reside in the home are the licensees Lillian and Earl Nelson who have fingerprint clearance. Per the licensee the large family childcare home operates Mon-Fri 6am-6pm. Incidental Medical Services (IMS) were discussed. Licensee is not currently providing IMS for any children in care.

This is a two story family home. The home consists of a formal dining room, formal living room, family room, kitchen, four bedrooms, three bathrooms, laundry area and attached garage. The primary care for children is conducted in the garage, kitchen and bathroom #1 located in the first hallway to the right. Children have access to the garage, kitchen, bedroom #1 and bathroom #1 (downstairs), family room and backyard. Per licensee a fire inspection has been completed. LPA observed cords that should be made inaccessible to the children. LPA observed licensee remove a space heater and place a cover in front of the faux fireplace/heater making it inaccessible to children. The family room has a fireplace that has been covered by a screen. LPA observed licensee remove fireplace pokers and place in pantry with key lock making inaccessible to children. LPA observed electrical outlets without covers. LPA advised licensee to place outlet covers over all outlets not in use in areas which make inaccessible to children. LPA observed licensee post current license and advised to remove old licenses that are not associated with the facility . LPA observed licensee remove BBQ pit in backyard during inspection. LPA observed complete records for children and staff.

The off-limit areas of the home include entire upstairs 3 bedrooms, bathroom #2 and #3 located in the master bedroom. The upstairs is made inaccessible by a gate. LPA observed a few toys and small playhouses for children play time in backyard.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 364818001
VISIT DATE: 03/15/2023
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The home was inspected inside for comfort, cleanliness, telephone service, heating and ventilation. Medications are stored in the master bedroom inaccessible to children. The kitchen knives are stored in the pantry and made inaccessible by key lock. Cleaning compounds are stored away in the pantry inaccessible to children.

The First Aid kit is located in the laundry room inaccessible to children. Per licensee, there are no weapons or firearms in the home. LPA did not observe any weapons or firearms. Smoke detectors are in operable condition. LPA confirm presence of a carbon monoxide detector that was in working condition. LPA advised to licensee provide confirmation of carbon monoxide detector with a current alarm system bill or verification of purchase with a receipt. The Fire Extinguisher was serviced on 10.2022 and meets the standards set by the State Fire Marshall. The licensee's provided Pediatric CPR/First Aid expires on 09/2024. Licensee provide proof of vaccination at time of visit . The licensee completed the required Mandated Reporter training on 9/8/2022. LPA advised licensee that Health and Safety Training (8 hrs) including lead poisoning prevention are required every two years.

The required posted documents were posted and located in the childcare room: Notification of Parent's Rights Poster (PUB394), Emergency Disaster Plan (LIC610A), and Earthquake Preparedness Checklist (LIC9148).

The following was discussed with the licensee:

Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; The licensee was reminded that 100% supervision is required at all times to children in care; Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care.

The licensee was informed that all adults living in or having access to the home, or are employees are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Central Index prior to having contact or working with children. If this is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analyst of any person who will be

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 364818001
VISIT DATE: 03/15/2023
NARRATIVE
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visiting regularly or for longer than one week. The licensee was advised to utilize the Request for Live scan Service LIC9163 to have adults fingerprinted and associated to the home.

The licensee was advised of the requirement to report Unusual Incidents. 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. The licensee was informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department.

The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, licensees, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Licensees must meet requirements as a precondition to licensure. New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com.

Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family childcare home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual -

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 364818001
VISIT DATE: 03/15/2023
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Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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/childqanda.htm

Lead Flyer Requirement Health and Safety Code 1596.7996, mandated that effective January 1, 2019, CCC's and FCCH's are required to provide parents and guardians of children enrolling or re-enrolling in care with written information on the risks and effects of lead exposure, blood lead testing requirements and recommendations, and options for locations of affordable blood lead tests as specified. A Lead Poisoning Facts Flyer was created, in partnership with the California Department of Public Health (CDPH), to satisfy this requirement.

The licensee was advised it is her responsibility to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov

Exit interview conducted with licensee, Lillian Nelson. A copy of the inspection report was provided to the Licensee.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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Document Has Been Signed on 03/29/2023 03:18 PM - It Cannot Be Edited


Created By: Kristina Diaz On 03/15/2023 at 02:01 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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 364818001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee will purchase and install carbon monoxide detector
Deficiency Dismissed
Type A
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee will correct all listed deficiencies
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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2023 03:18 PM - It Cannot Be Edited


Created By: Kristina Diaz On 03/15/2023 at 02:01 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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 364818001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee's nephew will be gone by Friday, 3/17/2023
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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/29/2023 03:18 PM - It Cannot Be Edited


Created By: Kristina Diaz On 03/15/2023 at 02:01 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: NELSON FAMILY CHILD CARE
FACILITY NUMBER: 364818001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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LIcensee will obtain all required immunization records and place in children's files by the due date
Deficiency Dismissed
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Licensee will update current roster with newly enrolled children by 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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023


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