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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750048
Report Date: 06/15/2023
Date Signed: 06/15/2023 12:31:57 PM

Document Has Been Signed on 06/15/2023 12:31 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:SBCSS BIG BEAR STATE PRESCHOOLFACILITY NUMBER:
367750048
ADMINISTRATOR:NANCY ALVARADO/KIM WEBERFACILITY TYPE:
850
ADDRESS:44500 BALDWIN LANETELEPHONE:
(909) 585-7766
CITY:SUGAR LOAF/BIG BEARSTATE: CAZIP CODE:
92386
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 11DATE:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Facility Representative Maria GonzalezTIME COMPLETED:
12:40 PM
NARRATIVE
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On June 15, 2023, at 11:45 a.m., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced case management deficiency inspection and met with facility representative Maria Gonzalez. LPA disclosed the purpose of the inspection and was granted entry into the facility. 11 children and two staff were present in the facility during this inspection.
On May 2, 2023, at 4:50 pm the Center called in an unusual incident report (UIR) to the Palmdale Regional Office for an unusual incident that occurred in “Mid-November” 2022. On May 8, 2023, during an unannounced inspection, LPA was provided with a written copy of the UIR. The facility failed to meet the reporting requirements. A deficiency is being cited based on the LPA record review in accordance with the California Code of Regulations, Title 22, see LIC809D.
A notice of site visit was given and must remain posted for 30 days. An exit interview was conducted, and the report was reviewed with facility representative Maria Gonzalez.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 06/15/2023 12:31 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 06/15/2023 at 11:41 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: SBCSS BIG BEAR STATE PRESCHOOL
FACILITY NUMBER: 367750048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting requirements (d)Upon the occurrence…a report... next working day…a written report…shall be submitted …within seven days following…event. (C) Any unusual incident …physical... emotional...safety... This requirement was not met as evidenced by:
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Per Facility Representative,
a plan will be submitted to the Department by 6/29/23 regarding how the Center will correct the situation to ensure that this does not happen again.
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Based on the record review, an unusual incident which occurred in Nov. 2022 was not reported to the Department until May 2023 which does not meet the reporting requirements. This posed a potential personal rights risk to the 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:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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