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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202198
Report Date: 06/28/2022
Date Signed: 06/28/2022 08:17:39 PM


Document Has Been Signed on 06/28/2022 08:17 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:WOODEN SHOE NURSERY SCHOOL, THEFACILITY NUMBER:
191202198
ADMINISTRATOR:MARTHA T VELOZFACILITY TYPE:
850
ADDRESS:1525 GLENOAKSTELEPHONE:
(818) 365-1513
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY:74CENSUS: DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Martha Veloz, DirectorTIME COMPLETED:
05:00 PM
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On 06/28/22, Licensing Program Analysts (LPAs) Justeene Tamayo and Donna Maddox met with the facility Director, Martha Veloz for the One Year Required inspection for the preschool in accordance with the facility sketch. A tour of the facility was conducted. Upon arrival LPAs observed 3 classrooms in use with a total of 17 preschool children (Classrooms:22B,23A, and 23B). There were 4 teachers on the premises and the Director. The hours of operation are 7am - 6 pm Monday - Friday. Incidental Medical Services (IMS) were discussed.

Indoor/Children’s Area:
Child care center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean, cleaning compounds inaccessible, poisons locked, furniture/equipment is good condition, free of flies, other insects, rodents; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, each child has an individual permanent or portable storage space (cubby, individually labelled with name) for his/her clothing, personal belongings and or bedding (stored separately). There is a working telephone.

Trash cans for solid waste have tight fitting lids, drinking water is readily available indoors and outdoors (Personal Cups with child's name labeled ----Drinking water is available inside the classrooms in the form of a drinking fountain to fill up each child's water bottle.. LPA observed a sufficient quantity of cots available for napping children. The bedding is stored separately and properly. All materials and surfaces are toxic free are inaccessible, no fireplace. There is a working Carbon monoxide detector, smoke detector and Fire Extinguisher (2A10BC).
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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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: WOODEN SHOE NURSERY SCHOOL, THE
FACILITY NUMBER: 191202198
VISIT DATE: 06/28/2022
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Staff/Personnel Records: Director (qualified) qualifications were verified, Designation of Responsibility observed, immunization's, TB clearance, health screening, criminal record statement, statement acknowledging suspected child abuse and mandated reporter were observed in file. After file review, it was determined staff #1, staff #3, and staff #6 have not received all of the required vaccinations. Facility has been cited two Type B Citations. Please see LIC 809-D.

Facility Records: Roster, disaster drill log last completed on 06/07/22, CPR/First Aid, and mandated report training were reviewed.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty.The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393L), emergency disaster plan, earthquake preparedness checklist.

Documents Provided and or Discussed: Forms and records to keep at the facility and IMS.

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. CPR/First Aid expires on 08/25/2022. Mandated Reporter Training expired yesterday 06/27/22. Per Director, she will retake the mandated reporter training and send to LPA Tamayo for proof of completion

Electrical outlets are inaccessible, recalled and or prohibited toys or sleep/play equipment were observed on the premises. There are no window cords accessible to children. Child nap on cots.

Sign in and out sheets were reviewed. The parent board was reviewed and has all of the required forms posted. Fire/earthquake drills current. Roster current.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WOODEN SHOE NURSERY SCHOOL, THE
FACILITY NUMBER: 191202198
VISIT DATE: 06/28/2022
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Teacher child ratios were observed and staff name recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.

Health Related Services: Medications inaccessible to children; all prescription and non-prescription medications have child’s name and are dated; written consent and instruction from child’s representative, a plan to document and report to child’s representative when medication is administered to a child; IMS plan on file (if applicable).

Children are inspected for illnesses (wellness policy) as they arrive. A review of medication policy indicated that prescription medication is administered only with parent's written permission (licensing medication form- LIC9221 - also used). The Director administers medication and documents the dosage, date and time onto a log. Medication can be brought and taken home by the parent daily. Medication is properly labeled and stored in its original container. There is a separate area for isolation and care of ill children at the entrance with the Director or Director office.

This facility provides Incidental Medical Services – IMS. Currently no IMS.
LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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/childquanda.htm

Food Service: There is a clean, fully equipped kitchen with refrigerator/freezer, microwave oven and stove. Per director, the children bring their own food in their own personal lunch bag. The facility has stocked water and snacks. The kitchen is currently off limits with lock on door.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: WOODEN SHOE NURSERY SCHOOL, THE
FACILITY NUMBER: 191202198
VISIT DATE: 06/28/2022
NARRATIVE
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Restrooms: LPA inspected and observed two clean bathrooms (4 toilets, 2 sinks,). LPAs observed paint chipping in the bathrooms. Per director, she will have the bathrooms repainted in August. Toilets and sinks are functioning properly and are age appropriate which is in safe and sanitary operating condition. LPA observed soap, toilet paper and paper towels readily available. Water temperature is appropriate. There is an isolation area for children who become ill while in care located in directors office, facility maintains a comfortable temperature at all times, first aid supplies (thermometer, bandages, scissors), sign in/out sheets (electronic) available and completed daily. No Smoking prohibited on the premises, daily inspection for illness, no prohibited child care items observed. Firearms/weapons are not allowed or stored on premises. There is no body of water on the premises.

Napping: LPAs observed childrens personal sheets in each cubby. Cots used are maintained in good condition, wiped/cleaned/disinfected (daily) weekly or when soiled, no contact with other children bedding.

Outdoor: The facility has 2 playground areas. The preschool children play in a gated area separated by a fence. On the other side of the play area is another play area for the preschool children. Outside play area is completely fenced. Outdoor play equipment was inspected for health, safety, good repair and age appropriateness. There i rubber matting and concrete areas for active play. The area was observed to be free of debris, free from hazard, holes, broken items, debris, cushioning material underneath. No bodies of water were observed. There are areas for shade and rest. Children use their personal water bottles for outside play.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WOODEN SHOE NURSERY SCHOOL, THE
FACILITY NUMBER: 191202198
VISIT DATE: 06/28/2022
NARRATIVE
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Director advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). 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.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Director shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of child care center or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process


A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
No deficiency. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.
Exit interview conducted and report was reviewed with Director Martha Veloz This report was read and provided to Director Martha Veloz, along with her appeal rights.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/28/2022 08:17 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: WOODEN SHOE NURSERY SCHOOL, THE
FACILITY NUMBER: 191202198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 . Staff #1,3 and 6 did not have all required vaccinations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Per licensee she will have all her staff retake the health screening to be current with all vaccinations no later than 08/30/22
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

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. Staff #1,3 and 6 did not have all required vaccinations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2022
Plan of Correction
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Per licensee she will have all her staff retake the health screening to be current with all vaccinations no later than 08/30/22

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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6