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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843657
Report Date: 03/29/2023
Date Signed: 03/29/2023 12:36:47 PM

Document Has Been Signed on 03/29/2023 12:36 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:KIDS & CARE PRESCHOOL & CHILD CARE CENTERFACILITY NUMBER:
364843657
ADMINISTRATOR:LUZ MARISOL VALENZUELAFACILITY TYPE:
840
ADDRESS:10662 MAPPLE AVENUETELEPHONE:
(760) 956-2000
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
03/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Luz Marisol Valenzuela, Site DirectorTIME COMPLETED:
12:30 PM
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On March 29, 2023, Licensing Program Analyst (LPA), Kuliema Calloway made an unannounced case management inspection to the above facility. LPA met with S1 who granted access. There were six school aged children and one staff in care.

The purpose of the inspection was to inform the licensee that on 1/9/2023, there was an unusual incident that occurred between Staff 1 and Child 1 where the facility failed to report the incident to Community Care Licensing Division.

There was one Type B citation issued during this visit. 101212 (d)(1)C for Reporting Requirements.

Exit interview was conducted and a copy of this report, Notice of Site Visit, and Appeals Rights were discussed and provided to the licensee at the facility.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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 03/29/2023 12:36 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 03/29/2023 at 11:52 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 & CARE PRESCHOOL & CHILD CARE CENTER
FACILITY NUMBER: 364843657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2023
Section Cited
CCR
101212(d)(1)(C)

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Upon occurrence, during operation of child care center any events specified... a report shall be made to CCLD by telephone,fax ...during business hours...written report within 7 days ...Any unusual incident... threatens the physical, emotional health,safety of any child. This requirement was not met as evidenced by:
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Licensee will train All staff on Reporting Requirements and provide proof that the training was conducted and completed to CCLD by: 4/10/2023.
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Based on LPA interviews, observation and record reviews the facility Licensee and staff failed to report an unusual incident involving Staff 1 and Child 1 to CCLD, which poses a potential risk to the Health, Safety, and Personal Rights risk to children 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.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023


LIC809 (FAS) - (06/04)
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