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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401106
Report Date: 04/06/2023
Date Signed: 06/16/2023 11:30:35 AM


Document Has Been Signed on 06/16/2023 11:30 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/16/2023 07:52 AM

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

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***This report is to amend the report dated on 4/6/2023***

On April 6, 2023, Licensing Program Analyst (LPA) Isabel Ortega met with facility Administrator/owner Nancy Anne E. Grunbok to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted to the Department on April 5, 2023. The unusual incident report is regarding a child injury at the facility on the outdoor play structure.

Upon arrival, there were 44 children observed in care and 8 staff proving care and supervision. During this inspection, LPA was provided with the facility roster and additional supporting documentation regarding the incident on 4/4/2023. In addition, LPA completed a safety inspection of the facility’s outdoor play structure. At the time of the inspection, children were engaged in outdoor play.

At this time further follow-up is needed. Director was informed the Department’s Investigation Bureau Investigator Laura Garcia will be following up on the unusual incident report.

An exit interview was conducted, and a copy of this report, notice of the site visit, and appeal rights were provided to the facility. A notice of site visit was provided and requested to be posted for 30 days.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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