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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840301
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:07:34 PM

Document Has Been Signed on 03/28/2024 04:07 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:BOUCHEY FAMILY CHILD CAREFACILITY NUMBER:
364840301
ADMINISTRATOR:BOUCHEY, STEPHANIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 954-4446
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/28/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Stephanie Bouchey, LicenseeTIME COMPLETED:
04:15 PM
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On 03/28/2024 Licensing Program Analyst (LPA) Ortega conducted an unannounced Annual Inspection. The LPA disclosed the purpose of the inspection and was granted entry. Upon entry to the home LPA observed nine children in care and two staff providing care and supervision.

This is a two-story-family home. There is a living room, dining room, kitchen, five bedrooms, three restrooms, a back yard, and an attached garage. Main care is provided in Room #1 referred to as the childcare play area and the living room and dining room. The off-limits areas are the bedrooms #2, #3, #4 and #5, the two restrooms which are located on the second floor (LPA observed a child safety gate at the bottom of the stairs), and the attached garage (maintained key locked). Children utilize the restroom next to bedroom #1 by the attached garage. Children utilize the back yard for outdoor play. The back yard is fenced all around.



Licensee provides children enrolled with breakfast, morning snack, lunch, afternoon snack and dinner as needed.
The operational childcare hours are Monday through Sunday varied up to 23 hours depending on parent’s need. Licensee provides over night care and transportation(a valid Driver's license and auto insurance observed.)
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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Document Has Been Signed on 03/28/2024 04:07 PM - It Cannot Be Edited


Created By: Isabel Ortega On 03/28/2024 at 02:09 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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee will log in and document every 15 minutes when an infant is napping and observed for signs of distress and position of all infants from 0-24 months. Licensee shall email LPA at the Palmdale Regional Office the log utilized to document the 15 min checks for infants by the due date indicated.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in licensee and Assistant do not have a current Child Care Provider Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee and staff shall take the Child Care Provider training on line at www.mandatedreporterca.com or in personal at approved locations and submit the certificates to the Palmdale Regional Office by date indicated.
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:Lady King
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 04:07 PM - It Cannot Be Edited


Created By: Isabel Ortega On 03/28/2024 at 02:09 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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. Licensee's Pediatric CPR/First Aid expired 6/14/2023.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee shall email LPA at the Palmdale Regional Office a copy of a renewed Pediatric First/Aid and CPR for licensee and Assistant(two) by the indicated dated. No online training is acceptable.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee shall provide legal guardian/Parent with the LIC9227 form and also complete an observation regarding mastering the rolling over development stage. These forms shall be placed on child's file and a copy shall be emailed to the Palmdale Regional Office by indicated 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:Lady King
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024


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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Knives, medication, cleaning supplies and chemicals are kept inaccessible to children (magnetic lock observed).

There are educational age-appropriate toys and equipment on the premises.

The First Aid kit with a temperature thermometer was observed and complete. The required fire extinguisher (2A10BC) is reading in green (last serviced on 6/12/2023). Smoke and carbon monoxide detector Dual (tested at 11:35 a.m.) and were found to be in operating condition.

Licensee had all the required documents: Facility License (LIC 203, Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148).

The licensee maintains proof of immunization against pertussis (TDAP), measles (MMR), TB and influenza.



Licensee’s Pediatric CPR/First Aid training certificate is dated 06/14/2021 which expire until 06/2023 (A Type B citation was issued today). Child Care Provider Mandated Reporter training (AB1207) is required to be renewed every two-years. Licensee and Assistants Child Care Provider Mandated Reporter (AB1207) training certificates are expired 2/2023. Emergency drills shall be conducted every six months, last drill was conducted today/documented 3/28/2024 at 2:00 p.m. (Completed during inspection technical violation given).
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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Licensee's facility child roster shall be current and maintained up to date.

The following were discussed: No smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category are permitted in the facility. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements and penalty. LPA observed a baby bouncer at the facility – infant was not observed utilizing bouncer. Removed during inspection to an off-limits area(technical Violation given).

Safe Sleep regulations (under 24 months) were discussed with Licensee and referred to the CCL web site for additional information and PINS. Infants under 2 years of age shall have the 15-minute checks logs completed during nap time. Safe sleep logs were not able to provide a notebook was demonstrated with nap time start time. (type B citation was issued). All infants under one year of age shall have the LIC9227 sleep plan completed by parent until infant master’s developmental stage of rolling over on their own. Licensee was not able to provide the LIC9227 forms on file for infants enrolled 0-12 months (type B citation was issued).

The licensee is aware all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analysis of any person who will be visiting regularly or for longer than one week.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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The Licensee was reminded 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. Licensee was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.

The following was also discussed with the licensee/The following items are zero tolerance by Licensing:



1. Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.
6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be evaluated.

7. The fire extinguisher Type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunization.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensees of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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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: BOUCHEY FAMILY CHILD CARE
FACILITY NUMBER: 364840301
VISIT DATE: 03/28/2024
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MyChildCarePlan.org-Family Child Care Homes Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Megan’s Law - Family Child Care Homes During the exit interview, according to licensee there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Child Care Advocates:


To sign up for our Quarterly Updates please email the Child Care Advocates at chilcareadvocatesprogram@dss.ca.gov & (916) 654-154.

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot line at 1-800-540-4000.

The facility was not found to be complying per Title 22 regulations, four deficiencies will be cited today. Technical violations were provided as a form of prevention. An exit interview was conducted, a copy of this Report, a Notice of Site visit and Appeal rights were provided and discussed with licensee.

All licensing reports are recommended to keep for 3 years, and the Notice of Site visit is to be posted visible to parents for 30 days. LPA informed Licensee about Technical Support Program (TSP)

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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