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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 147700001
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:04:55 PM


Document Has Been Signed on 03/23/2023 01:04 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:Ayala Family Child CareFACILITY NUMBER:
147700001
ADMINISTRATOR:Mirta AyalaFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 228-4055
CITY:BishopSTATE: CAZIP CODE:
93514
CAPACITY:14CENSUS: 5DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mirta Ayala De Soto and Jesus Tapia SotoTIME COMPLETED:
01:15 PM
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On 3.23.23, Licensing Program Analyst (LPA) Kris Diaz conducted an unannounced Annual inspection. LPA met with Licensee, Mirta Ayala De Soto who guided LPA on a tour of the home. People who reside in the home are the licensees, Mirta Ayala De Soto and Jesus Tapia Soto who have fingerprint clearance. The licensees have the required immunizations against pertussis (TDAP), measles (MMR) and flu declination. 5 childcare children were present. Per the licensee the small family childcare home operates Mon-Sat 5:00am-5:30pm. Incidental Medical Services (IMS) were discussed. Per the licensee, she does not have children who need IMS currently.

This is a one-story family home. The home consists of two bedrooms, two bathrooms, dining room, living room, kitchen, laundry area, porch, and yard. The primary care for children will be conducted in the living room, kitchen, and bathroom #1 located down the hallway to the right. Children will have access to the living room, kitchen, bathroom #1, and the backyard. There is a television in the living room that should be anchored to the wall. The living room has a wood stove that has a gate surrounding it making it inaccessible to the children. LPA observed toys and books in childcare room appropriate for children. LPA observed licensee remove swing that is prohibited in FCCH. LPA observed 4 cots, a baby cot for infants, pillows, and blankets for napping. LPA observed 2 highchairs and a table and chairs for dining. Per licensee, there are no children with food allergies in care currently. LPA reminded licensee that should children with allergies enroll in the facility food should be properly labeled and stored. Per licensee, parents provide food for children and food is properly stored. LPA observed knives and sharp objects stored in upper cabinet in kitchen. LPA advised licensee to put a safety latch on cabinet to make inaccessible to children.

The off-limit areas of the home include 2 bedrooms, bathroom #2 located in the master bedroom, and the side yard area which is made inaccessible to children with gate. The backyard contains a playhouse, a sandbox, and other age-appropriate toys. LPA observed a play structure that is inappropriate for children. LPA advised licensee to remove. LPA observed rose bushes that could cause injury to children. LPA advised

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kristina DiazTELEPHONE: (661) 202-3372
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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: Ayala Family Child Care
FACILITY NUMBER: 147700001
VISIT DATE: 03/23/2023
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licensee to make the rose bushes inaccessible to children. LPA observed an area behind the storage covered by a board. LPA advised licensee that area should be made inaccessible to children. LPA observed two storage structures that are inaccessible to children with key padlock.

The home was inspected inside for comfort, cleanliness, telephone service, heating, and ventilation. Medications are stored in the master bedroom inaccessible to children. Cleaning compounds are stored away in the laundry area inaccessible to children.

The First Aid kit is in front living room closet inaccessible to children. Per licensee, there are no weapons or firearms in the home. LPA did not observe any weapons or firearms. Smoke detectors are in operable condition. The home has a carbon monoxide detector that is operable. The Fire Extinguisher (10-A:2-B:C) was serviced on 05/2022 and has a green indicator. Fire extinguisher meets standards set by State Fire Marshall. The licensee's Pediatric CPR/First Aid expires on 04/09/2024. The licensee has not completed the required Mandated Reporter training. LPA advised licensee that training must be completed as soon as possible. Health and Safety Training was not completed. LPA advised licensee that must be completed as soon as possible.

The required posted documents were posted and located in the childcare room: 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.

The licensee was informed that all adults living in or having access to the home, or are employees are required to have fingerprint clearances with Department of Justice, FBI, and Child Abuse Central Index prior to having contact or working with children. If the is not adhered to, a Civil Penalty of up to $500, per

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kristina DiazTELEPHONE: (661) 202-3372
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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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: Ayala Family Child Care
FACILITY NUMBER: 147700001
VISIT DATE: 03/23/2023
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non-cleared adult will be assessed immediately. Please advise your analysis of any person who will be visiting regularly or for longer than one week. The licensee was advised to utilize the Request for Live scan Service LIC9163 to have adults fingerprinted and associated to the home.

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.

The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

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. Licensees 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.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kristina DiazTELEPHONE: (661) 202-3372
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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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: Ayala Family Child Care
FACILITY NUMBER: 147700001
VISIT DATE: 03/23/2023
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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. 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

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.

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

The following Type B citations were issued:

Physical Plant - Type B: 102417(g)(9)(A) - Per licensee, fire and emergency drills have not been performed with children in care; LPA provided licensee with guidance and tips on performing drills and log sheet for tracking. LPA advised licensee that drills should be performed and recorded every six months.


Facility Administration - Type B: 1596.8662(b)(1) - LPA discussed mandated reporter requirements with licensee; LPA advised licensee that mandated reporter training should be completed as soon as possible.

Records - Type B: 102418(g) - LPA did not observe immunization records in files of children in care; Per licensee, will obtain records from parents as soon as possible.

Exit interview conducted with licensee, Mirta Ayala De Soto. A copy of this report, appeal rights and notice of site visit were left with the licensee.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kristina DiazTELEPHONE: (661) 202-3372
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/23/2023 01:04 PM - It Cannot Be Edited

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: Ayala Family Child Care
FACILITY NUMBER: 147700001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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Per licensee, fire and emergency drills will be completed every six months; Licensee will conduct drills by POC due date and send picture to LPA of log upon completion.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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LPA advised licensee that training must be completed by POC due date; Per licensee, will send certificates upon completion.
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 YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kristina DiazTELEPHONE: (661) 202-3372
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/23/2023 01:04 PM - It Cannot Be Edited

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: Ayala Family Child Care
FACILITY NUMBER: 147700001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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LPA advised licensee to provide proof of TB skin test by POC due date or contact LPA with record of appointment; Per Licensee, will send proof of test or appointment by POC due date.
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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Per licensee, will obtain records from parents by POC due date and provide proof of correction to LPA.
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 YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kristina DiazTELEPHONE: (661) 202-3372
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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