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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700284
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:56:43 PM

Document Has Been Signed on 05/15/2024 02:56 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:GREEN FAMILY CHILD CAREFACILITY NUMBER:
367700284
ADMINISTRATOR/
DIRECTOR:		KINA & KYNUNULA GREENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 514-2227
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
05/15/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:07 PM
MET WITH:Kynunula Green, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On May 15, 2024, Licensing Program Analyst (LPA) Calloway made an unannounced inspection to the above facility. LPA met with Licensee, who granted access. LPA and Licensee toured the home inside and outside for an Annual Random inspection. Residing in the home are the Licensee, Licensee’s spouse, two minor children. The home is licensed for twelve to fourteen children. LPA observed seven (7) napping day care children in care with licensee during inspection.
Physical Plant: This is a single story 3-bedroom, 2-bathroom home with kitchen, dining room, family room, living room, and garage. Childcare is provided: in the living room upon entry. Children’s Bathroom: is in hallway on the left it was observed clean, with soap and toilet paper, there were shampoos observed in the shower that were removed during inspection. Unused outlets in the home were covered. Blind cords were cordless. Age-appropriate toys, furniture, and books observed. Napping equipment (cots, playpen) observed enough for all children. The home was inspected inside and outside for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, hazardous detergents/cleaning compounds kept in garage with a safety knob, mKitchen: items that can pose a danger to children were not inaccessible. LPA recommended a gate across. The sharp knives were in kitchen cabinet up high. Fire/earthquake drills current (completed-July 2023- not current). Child/Parent Roster (incomplete). Medicines kept in off limits bedroom. Windows screened, free of bugs, cracks, and debris.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284
VISIT DATE: 05/15/2024
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Kitchen: items that can pose a danger to children were not inaccessible. LPA recommended a gate across. The sharp knives were in kitchen cabinet up high. Fire/earthquake drills current (completed-July 2023- not current). Child/Parent Roster (incomplete). The required fire extinguisher (2A10BC) (full/green). Smoke and carbon monoxide detectors were tested (operable). Fireplace is screened. Home has central AC and heat. Required postings were present on the wall. There is a landline phone, and cell phone. Fire alarm pull (observed).
Off limit areas: Garage (safety knob), Bedrooms: #1, #2, #3 (safety knobs), Bathrooms: #2, and laundry inside the garage.
Outside: The backyard is completely fenced. Toys, bikes, and play equipment were observed. There is no pool/spa but one body of water on the premises. AC unit in the yard was fenced around. There is a water fountain in the far-right corner that is empty, and an unlocked storage shed. LPA recommended shed be always locked during day care hours.
Others: Per Licensee, there are no weapons or firearms on the premises. LPA did not observe any in the home. Required mandated reporter training (current), CPR/First Aid (Exp: 7/24), and immunizations (current). First Aid kit observed. LPA viewed staff and children’s files. No infants are in care. LPA conducted a staff interview with the licensee. Transportation is not provided. Incidental Medical Services (IMS) policy and Safe Sleep regulations were discussed.
The following was discussed with the Licensee:
Maintain capacity and transparency per posted parent rights, Roster requirements (keep updated information always), Documentation for disaster drills (fire and earthquake). Mandatory forms, signed, for the children’s/staff files, know updated Safe Sleep regulations. The role and responsibilities of being a mandated reporter. Supervision is always required for children in care.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284
VISIT DATE: 05/15/2024
NARRATIVE
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Check food expiration dates periodically. Responsible for knowing the regulations as well as anyone who assists in providing care. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. If day care is closed for the day, no kids show, or Licensee absent, must notify Licensing. Inaccessibility of hazards must be constantly reassessed depending on the children in care. If the phone number is changed, licensing must be notified. Regulations prohibit the smoking of tobacco in a private residence that is licensed as a family childcare home and areas of the day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exer saucers, and any other items that fall into that category.
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. 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.
Type A deficiency: Type A deficiency shall be posted for 30 consecutive days along with the Notice of Site Visit Letter (printed out after every visit) and posted during hours of operation, as there is an immediate risk to the health, safety, or personal rights of children in care. Licensee shall provide a copy any Type A deficiency to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of the Type A report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in the children's files for verification of the Type A deficiency. Failure to do so will result in a civil penalty being assessed.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284
VISIT DATE: 05/15/2024
NARRATIVE
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--Licensee is advised to visit: www.shotsforschool.org for Immunization information.
--Licensee was informed of their responsibility to report suspected Child Abuse (LIC 9108), 1-800-827-8724/760-243-6640. Licensee was informed of the MyChildCarePlan.org website, a
consumer education website that helps families obtain childcare by connecting them to child
care providers and Resource and Referral Agencies (R&Rs) throughout California.
--Family Child Care Providers (Disaster Planning information):
https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Child Care Videos: https://ccld.childcarevideos.org
--Licensee advised to visit the CCLD website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department prior to providing the IMS. 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: http://www.ada.gov/childqanda.htm.
--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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284
VISIT DATE: 05/15/2024
NARRATIVE
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 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.
-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 inspection process@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.
--Lead Poisoning: For more information, go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600.
Reminder: The On- Duty Worker is available for questions at: (661) 202-3318 (Monday-Friday 8am-5pm) and for reporting Unusual Incident Reports (within 24 hours). Written Unusual Incident Reports are sent (using (LIC 624B form) to the following email address: unusualincidentreport@dss.ca.gov within seven (7) days after reporting the incident via telephone.

Per Title 22 Regulations, Division 12, Chapter 1, there are deficiencies cited during this inspection. See 809 D pages.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit, were Appeal Rights, provided to Licensee during the inspection. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting will result in $100 civil penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2024 02:56 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/15/2024 at 02:37 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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

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 in Licensee did not have an updated disaster drill during inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will provide proof of disaster drill to Licensing by 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.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


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Document Has Been Signed on 05/15/2024 02:56 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/15/2024 at 02:37 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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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 in C5 did not have immunization records in their files during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will provide proof of immunization for child to Licensing by POC date.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 in the roster was missing physician's information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will provide proof of updated roster to Licensing by 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.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/15/2024 02:56 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/15/2024 at 02:37 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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 367700284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 in Child 6 was missing their LIC 995 form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will provide proof of LIC 995 form by 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.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


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