<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153808551
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:39:54 PM


Document Has Been Signed on 04/13/2022 03:39 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:FALLER STATE PRESCHOOLFACILITY NUMBER:
153808551
ADMINISTRATOR:MICHELLE A ARMSTRONGFACILITY TYPE:
850
ADDRESS:1500 WEST UPJOHNTELEPHONE:
(760) 499-1694
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:24CENSUS: 22DATE:
04/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Site Supervisor Lizeth Robles and Director Michelle ArmstrongTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 13, 2022 at 12:16PM, Licensing Program Analyst (LPA) Brigitte Tsutaoka conducted an unannounced complaint inspection for complaint 12-CC-20220211095950. LPA disclosed the purpose of inspection and was granted entry by Site Supervisor Lizet Robles, who guided LPA on a tour of the facility. LPA observed 22 children with 3 staff on association list. At 1:00PM, Director Michelle Armstrong arrived at the facility.

During the course of the investigation, it was disclosed a separate incident occurred involving Staff 1 (S1) who swatted away the hand of Child 1 (C1). S1 had finished disinfecting blocks, C1 grabbed a block after it was cleaned, and S1 swatted away C1's hand, making brief contact. C1 did not have any marks or bruising, and C1 reacted by swatting at S1's hand in return. The incident was not reported to Licensing in the required time identified in Title 22 regulations.

Director disclosed the facility handled the incident internally. A Zoom meeting was held with S1, Director, and Site Supervisor, and the incident was addressed. Facility provided a copy of the written reprimand issued to S1 which included a written statement disclosing the incident that occurred. S1 no longer works for the facility.

Based on evidence gathered, a violation of Title 22 regulations did occur. California Code of Regulations Title 22, Division 12, Chapter 1 101212 Reporting Requirements Type B violation and 101223 Personal Rights Type A violations are being cited during inspection. See LIC809D for deficiency details.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 04/13/2022 03:39 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: FALLER STATE PRESCHOOL
FACILITY NUMBER: 153808551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited

1
2
3
4
5
6
7
101212 Reporting Requirements (d) ...A report shall be made to the Department by telephone or fax within the Department's next working day... In addition, a written report ... shall be submitted to the Department within seven days following the occurrence of such event. This requirement was not met as evidence by:
8
9
10
11
12
13
14
Based on interview and record review, Director failed to submit an incident report to the Department within the time frame specified in the regulation, which poses a potential Health and Safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/13/2022 03:39 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: FALLER STATE PRESCHOOL
FACILITY NUMBER: 153808551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2022
Section Cited

1
2
3
4
5
6
7
101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment. This requirement was not met as evidence by:
8
9
10
11
12
13
14
Based on interview and record review, facility staff hit the hand of Child 1, which poses an immediate Health and Safety risk to children in care.
8
9
10
11
12
13
14
and submit signatures after watching video no later than 4/14/2022.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: FALLER STATE PRESCHOOL
FACILITY NUMBER: 153808551
VISIT DATE: 04/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Director was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. A copy of this licensing report (LIC809) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent and a copy of the Acknowledgment of receipt of licensing report (LIC9224) must be kept in each child's file. In addition, any child enrolled within the following 12 months must also receive a copy of the Type A Citation.

An exit interview was conducted, a copy of this Report, Appeal Rights, and Notice of Site Visit were provided to Director, Michelle Armstrong.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4