<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700046
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:34:42 PM

Document Has Been Signed on 11/21/2023 02:34 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:JENSEN FAMILY CHILD CAREFACILITY NUMBER:
367700046
ADMINISTRATOR:JENSEN, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 963-6114
CITY:BARSTOWSTATE: CAZIP CODE:
92311
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Licensee Maria JensenTIME COMPLETED:
02:52 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/21/2023 at 12:21pm, Licensing Program Analyst (LPA) Andrea Pittman conducted an unannounced case management visit at the facility and was met by Licensee Maria Jensen who permitted entry to the facility. LPA toured the facility with the Licensee according to the facility sketch. Upon arrival, LPA observed 7 children with 3 staff members providing care and supervision.

On 10/27/2023, the Licensee Maria Jensen submitted a LIC 624B- Unusual Incident Report stating that an incident occurred on 10/27/2023 at 9:10am in the home where Child 1 sustained an injury to back of their head that required medical attention. After observations, interviews, and record reviews, the following information was revealed about the incident resulting in the submission of the LIC 624B-Unusual Incident Report:

LPA received pertinent documents related to this investigation, which included the children’s rosters, staff contact information, and other relevant investigation documents. It was revealed that Staff 2 was sitting in the kitchen at the table while on break when the incident occurred. The Licensee was also in the kitchen preparing to drop a child off at a program. Staff 1 was the only staff member in the day care room when the incident occurred with Child 1. The day care children were sitting at the table eating breakfast when Child 1 stood up from the table. Staff 1 instructed Child 1 to sit down as they had not finished eating. As Child 1 sat down, the chair slid from under them and they fell to the floor, striking their head against the seat of the chair causing a small 1/4 inch gash in the back of their head. The Licensee rendered first aid by placing an ice pack to the head of Child 1. Additionally, the Licensee notified the authorized representatives of Child 1's injury and recommended them to seek medical treatment. The authorized representative immediately came and took Child 1 to their medical center. Child 1 was treated and later returned to the child care facility at lunch time with the Authorized Representative to show the Licensee that Child 1 was okay and then Child 1 was taken home by the authorized representative. Child 1 returned to the facility on the next business day, Monday, 10/30/2023. The Licensee completed the proper reporting of the incident to Licensing and completed and submitted the forms. LPA Pittman provided technical assistance in reporting requirements.

Continue to next page

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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
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: JENSEN FAMILY CHILD CARE
FACILITY NUMBER: 367700046
VISIT DATE: 11/21/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As a result, there are no citations being cited at this time. The facility took proper action in protecting the children in care and properly reporting. The Licensee is advised to continue to report any unusual incidents as they may occur in the facility.

All Licensing reports are recommended to be kept for three years.



An exit interview was conducted, and a copy of this report was provided to the Licensee along with the Notice of Site Visit and Appeal Rights.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2