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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700110
Report Date: 09/02/2025
Date Signed: 09/02/2025 02:07:19 PM

Document Has Been Signed on 09/02/2025 02:07 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HOLGUIN FAMILY CHILD CAREFACILITY NUMBER:
367700110
ADMINISTRATOR/
DIRECTOR:		HOLGUIN, TINAMARIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 910-3009
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/02/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:TinaMarie Holguin- LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On Tuesday, September 2, 2025, Licensing Program Analyst (LPA)Braddock, conducted an unannounced annual inspection. LPA met with Licensee, TinaMarie Holguin who guided LPA on a tour of the home. People who reside in the home are (Licensee and Spouse, who are live scanned and have TB skin test on file and minor child (17). The large family childcare home operates Monday through Friday 7am to 5pm. At the time of the visit there were 5 children present with 2 staff members.

This is a single-story house with 3 bedrooms, 2 bathrooms, kitchen/dining room, living room, bedroom and attached garage. Licensee states the following areas of the home are being utilized for the Family Child Care: Living Room, one restroom and the backyard. The off-limits of the home is 3 bedrooms, one bathroom, Kitchen/dinning and garage. There is a fireplace located in the living room which is inaccessible to children with a wood barrier blocked. There is not a swimming pool/body of water on the premises. LPA observed one dog.

The home was inspected inside for comfort, cleanliness, telephone service, heating and ventilation. Medications are stored in the garage inaccessible to children. The kitchen knives are stored garage and made inaccessible by a key locked door. Cleaning compounds are stored in the garage inaccessible to children.

The First Aid kit is located garage inaccessible to children. Per licensee, there are no weapons or firearms in the home. LPA did not observe any weapons or firearms. Smoke detectors and carbon monoxide detectors are in operable condition.

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NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sherell Braddock
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/02/2025 02:07 PM - It Cannot Be Edited


Created By: Sherell Braddock On 09/02/2025 at 01:39 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: HOLGUIN FAMILY CHILD CARE
FACILITY NUMBER: 367700110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above because the infant had loose articles in the pack n play while sleeping which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
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Licensee removed the articles from the pack n play in front of LPA.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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 documenting safe sleep every 15 minutes which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
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Per icensee she will complete a declaration and provide it to LPA pror to POC 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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Sherell Braddock
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HOLGUIN FAMILY CHILD CARE
FACILITY NUMBER: 367700110
VISIT DATE: 09/02/2025
NARRATIVE
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The Fire Extinguisher is green, fully charged, and meets the standards of the State Fire Marshal. The licensee’s Pediatric CPR/First Aid expires on 10/8/25. The licensee has the required immunizations against pertussis (TDAP) and measles (MMR) and Influenza. The licensee completed the required Mandated Reporter training on 5/29/24. Preventative Health and Safety Training is completed.

The required posted documents were posted and located on the parent wall: Notification of Parent's Rights Poster (PUB394), Emergency Disaster Plan (LIC610A), and Earthquake Preparedness Checklist (LIC9148).

The following was discussed with the licensee:

Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; The licensee was reminded that 100% supervision is required at all times to children in care; Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care.

LPA discussed the safe sleep regulations with licensee 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. Per LPA observation an infant was sleeping in the pack n play and there were loose articles in the pack n play. Licensee will receive a TYPE B citation. Per LPA observation LICENSEE was not documenting safe sleep checks every 15 minutes, Licensee will receive a type B citation. LPA printed out safe sleep documents and provided them to Licensee. LPA also informed licensee 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.

Licensee 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. Page 2

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sherell Braddock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HOLGUIN FAMILY CHILD CARE
FACILITY NUMBER: 367700110
VISIT DATE: 09/02/2025
NARRATIVE
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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 advised of the requirement 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 LIC624B when submitting the report to the department.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, licensees, directors, and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Licensee 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.

Prior to making alterations or additions to a family childcare home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "childcare" room; Room additions to the family childcare home. Any change from an area of the family childcare home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition, or construction.

This facility does not provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

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NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sherell Braddock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HOLGUIN FAMILY CHILD CARE
FACILITY NUMBER: 367700110
VISIT DATE: 09/02/2025
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Lead Flyer Requirement Health and Safety Code 1596.7996 mandated that effective January 1, 2019, CCC's and FCCH's are required to provide parents and guardians of children enrolling or reenrolling in care with written information on the risks and effects of lead exposure, blood lead testing requirements and recommendations, and options for locations of affordable blood lead tests as specified. A Lead

Poisoning Facts Flyer was created, in partnership with the California Department of Public Health (CDPH), to satisfy this requirement.

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.

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.

The licensee was advised it is her responsibility to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov

Please see 809 -D

LPA confirmed that there are no Registered Sex Offenders living in the facility and completed the RSO profile in FAS during the file review. This inspection visit was conducted in person. The report was read, and a copy was provided to the Licensee TinaMarie Holguin. Notice of Site Visit was given and must remain posted for 30 days. Exit interview was conducted.

Last page

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Sherell Braddock
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
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