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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 05:02:36 PM

Document Has Been Signed on 06/06/2023 05:02 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:
(760) 951-5002
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Earl NelsonTIME COMPLETED:
03:30 PM
NARRATIVE
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On 06/06/23, Licensing Program Analyst (LPA) Babatunde Ibitoye met with licensee for the purpose to provide an amended Facility Evaluation Report for the Case Management Report dated 03/15/23. The report was amended to dismiss a type B citation at first level appeal and other corrections.

Licensing Program Analyst (LPA) Kris Diaz and Licensing Program Manager (LPM) Claretta Yates met with the Licensee, Lillian Nelson for a case management incident inspection involving an Unusual Incident Report (UIR) received via mail on 1/31/2023 LPA and LPM toured the facility and took a census of the children. Upon arrival, there were 4 children and 2 staff present today.

Description of the incident: On 1/24/2023 at approximately 2:30-3:00 PM, C1 and C2 were in the play room being supervised by a staff member. Children were playing and running around when C2 alerted the staff member that C1 had inappropriate contact with C2.

The unusual incident follow up was conducted by the Department's Investigator Georgina Tallagua. The incident between C1 and C2 occurred as children were playing and the incident was unintended. No violation occurred. Licensee is encourage to continue to report unusual incidents that occurred at the facility. An exit interview was conducted, and a copy of this report was read and provided to the licensee on this date, along with a copy of her appeal rights and Notice of Site Visit.
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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See Facility Evaluation Report LIC 809D for deficiency.

Type B CCR 102416.2
102416.2(d)(1): The licensee shall report to the Department as provided in Health and Safety Code Sections 1597.467(b)(1). Health and Safety Code Section 1597.467(b)(1) provides in part:
“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 a family day care home of the events.”
This requirement is not met as evidenced by:
The receipt of the UIR dated 1.24.23 received by the PRO on 1.31.23.
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 03/27/2023 03:03 PM - It Cannot Be Edited


Created By: Kristina Diaz On 03/15/2023 at 02:58 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/15/2023
Section Cited
CCR
102416.2(d)(1)

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(d) The licensee shall report to the Department as provided by Health and Safety Code Sections 1597.467(b)(1) and (2).
(1) Health and Safety Code Section 1597.467(b)(1) provides in part:
"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 of…the…events."
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Licensee will report all unusual incidents to the Regional Office (RO) OD within 24 hours of the incident and submit an LIC624 to RO by mail or fax within 7 business days.

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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


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