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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700046
Report Date: 03/07/2024
Date Signed: 06/10/2024 12:37:48 PM

Document Has Been Signed on 06/10/2024 12:37 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: 4DATE:
03/07/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Licensee Maria JensenTIME COMPLETED:
01:00 PM
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On 3/7/2024 at 8:34am, Licensing Program Analyst (LPA) Andrea Pittman conducted an unannounced annual inspection. The LPA disclosed the purpose of the inspection and was permitted entry by the staff, the Licensee soon joined, thereafter. The Licensee guided the LPA on a tour of the home. Upon entry to the facility, the LPA observed four children in care and four staff providing care and supervision (fingerprint cleared and associated to the center.)

The operational childcare hours are Monday through Friday, 6:00am to 6:00pm; however, the Licensee completed the LIC 279A to update their child care hours to Monday through Sunday and varies up to 23 hours for parent’s needs.

This is a one-story family home. There is a living room, kitchen, three bedrooms, two bathrooms, laundry area, and a converted garage but is not accessible to the children in care. The Licensee does provide napping, there are fourteen cots and four playpens. The off-limits areas are the two bedrooms, second bathroom, laundry area, and converted garage. Licensee provides breakfast, lunch, dinner, and snacks. 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. Hanging window blind cords: There are no cords on the window blinds. Pets: there are no pets on premises. Phone service: There is a working cell phone, charged and kept on Licensee at all times. Transportation: The Licensee does provide transportation for children, they are aware that they must have a valid driver license, the vehicle has to be insured, and registered. Isolation occurs in the first bedroom on the right in the hallway that is part of the on-limits area for children in care showing signs of illness. Calming occurs in the corner of the living room.

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SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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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: 03/07/2024
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Knives are kept in the kitchen on top of the refrigerator in a box, inaccessible to children in care. Medication is kept in the kitchen in a high cabinet, inaccessible to children in care. Cleaning supplies and chemicals are kept in the laundry area and inaccessible to children in care.

There are age-appropriate toys and equipment on the premises. The outdoor area is free from sharp objects, broken toys/furniture & equipment, and other debris. Per the Licensee, there are no weapons, firearms, and ammunition in the facility. The LPA did not observe any weapons. Per the Licensee, there is no smoking on the premises.

The First Aid kit included a temperature thermometer, tweezer, scissors, gauzes, adhesive tape, and cleansing pads/solution was observed to be complete and inaccessible to children kept in a hallway cabinet secured with a safety knob. The required fire extinguisher (2A10BC) is reading in green, last tested on 1/2/2024. Smoke and carbon monoxide detectors were found to be in operable condition, tested at 9:32am and 9:33am, respectively. Fire and Disaster drills are conducted at least every six-month, last drills were recorded on 10/4/2023 at 10:00am for the drills.

Licensee had all the required posted documents: Facility License (LIC 203, Notice of Parent's Rights Poster (PUB 394), and Emergency Disaster Plan (LIC 610A); however, the Earthquake Preparedness Checklist (LIC 9148) was missing, the form and technical assistance was provided.

Licensee has insurance coverage for the facility from National Liability & Fire Insurance Company expiring 10/2024.

The Licensee provided proof of immunization against pertussis (TDAP), TB, and Influenza vaccination for self; however, the measles (MMR) vaccine is missing for the Licensee; also, the Licensee’s significant other that has significant contact is missing proof of TB.


Licensee was able to provide a valid Pediatric CPR/First Aid training valid until 1/2025. Child Care Provider Mandated Reporter Training Certificate has been completed and valid until 2/2026. Staff Personnel files were complete with the: LIC 9052-Notice of Employee Rights, LIC 9108-Statement Acknowledging Requirement to Report Child Abuse, Mandated Reporter Training, background clearances, and Pediatric First Aid & CPR. Immunizations: all staff are missing the MMR vaccine and the Tdap is missing for Staff 1 and Staff 2, TB is missing for Staff 1 and the significant other, & Flu shots/statements declining the Flu shot were in the personnel files.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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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: JENSEN FAMILY CHILD CARE
FACILITY NUMBER: 367700046
VISIT DATE: 03/07/2024
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The missing immunizations and TB for the staff and significant other is a Type B violation, see the LIC 809D for the details.
Children’s records: files were found to include the following required documents: LIC 700-Identification and Emergency Consent, LIC 627-Consent for Medical Treatment, LIC 995A-Notification of Parent’s Rights, LIC 995E-Caregiver Background Check Process, and LIC 9150- Parent Notification of Additional Children in Care, LIC 9212-Family Child Care Consumer Awareness Information, and PM 286-California School Immunization Record.

Licensee's facility child roster is 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 which are not permitted in the facility. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files, posting requirements, and penalties.

Facility Representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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. The Licensee was informed to utilize the Unusual Incident Report/Injury Report Form LIC624B when submitting the report to the department.

LPA discussed the safe sleep regulations with the Facility Representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/
safe-sleep as an additional resource.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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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: JENSEN FAMILY CHILD CARE
FACILITY NUMBER: 367700046
VISIT DATE: 03/07/2024
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LPA also informed the Facility Representative 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.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure. 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 22-02-


CCP. 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/.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.



During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and the RSO profile has been completed in FAS.

Child Care Advocates:
To sign up for our Quarterly Updates please email the Child Care Advocates at
chilcareadvocatesprogram@dss.ca.gov & (916) 654-1541.
The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000.

Per Title 22 Regulations, this facility is not in compliance, a Type B Deficiency has been cited. Please, see the LIC 809D for the citation.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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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: JENSEN FAMILY CHILD CARE
FACILITY NUMBER: 367700046
VISIT DATE: 03/07/2024
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An exit interview was conducted, a copy of this Report, a Notice of Site visit, and Appeal rights were provided and discussed with the Facility Representative.

All licensing reports are recommended to be kept for 3 years. The Notice of Site visit is to be posted and visible to parents for 30 days.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2024 12:37 PM - It Cannot Be Edited


Created By: Andrea Pittman On 03/07/2024 at 12:10 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: JENSEN FAMILY CHILD CARE
FACILITY NUMBER: 367700046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having proof of immunizations for Staff 1, 2, 3, and Licensee for the MMR vaccine and Staff 1 & 2 for the DTP vaccine, and TB results for Staff 1 and the Licensee's significant other which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Licensee will send proof via e-mail of the missing vaccines and TB results no later than 4/4/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mariela Ramon
LICENSING EVALUATOR NAME:Andrea Pittman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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