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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364830159
Report Date: 01/14/2022
Date Signed: 01/14/2022 11:13:46 AM

Document Has Been Signed on 01/14/2022 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KIDS AND CARE PRESCHOOL & DAY CARE CENTERFACILITY NUMBER:
364830159
ADMINISTRATOR:CLAUDIA VALENZUELA GARCIAFACILITY TYPE:
830
ADDRESS:9560 I AVENUETELEPHONE:
(760) 956-5000
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 13DATE:
01/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Katrina HendersonTIME COMPLETED:
11:28 AM
NARRATIVE
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Licensing Program Analyst (LPA) Thompson-Miller visited the facility for a different purpose. During the visit, LPA observed there was not an Unusual Incident Report (LIC624) submitted to Community Care Licensing for the heating system not working. See LIC809D for deficiency cited per California Code of Regulations Title 22, Division 12. Deficiency (LIC624 provided) cleared during today's visit.

An exit interview was conducted, report was read and provided to Assistant Director, Katrina Henderson on this date. Appeal rights were provided and discussed. Notice of Site Visit was posted and must stay posted for 30 days
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/14/2022 11:13 AM - It Cannot Be Edited


Created By: Linda Thompson-Miller On 01/14/2022 at 10:17 AM
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: KIDS AND CARE PRESCHOOL & DAY CARE CENTER
FACILITY NUMBER: 364830159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2022
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting Requirements(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information
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Center provided the LIC624 Unusual Incident Report to indicate the heating system was not working since November 2021 and has been repaired as of January 13, 2022.
Cleared during visit today.
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specified in (d)(1) and (d) (2) below shall be submitted to the Department within seven days following the occurrence of such event.(1) Events reported shall include the following:(C) Any unusual incident. This requirement was not met as evidenced by: The center did not report the heating system was not working.
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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:Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2022


LIC809 (FAS) - (06/04)
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