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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402255
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:04:00 PM


Document Has Been Signed on 08/11/2023 03:04 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:CHANG FAMILY DAY CAREFACILITY NUMBER:
197402255
ADMINISTRATOR:MARIA DE JESUS CHANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 253-7308
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:14CENSUS: 3DATE:
08/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria De Jesus ChangTIME COMPLETED:
03:15 PM
NARRATIVE
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On 8/11/2023 Licensing Program Analyst (LPA) Ortega met with licensee to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a uncleared adult in the home present on 7/06/2023. This inspection is regarding a potential risk to children in care. Upon arrival, there were 3 children and Licensee providing care and supervision.

During this inspection, LPA reviewed the facility history, conducted child and staff interviews. LPA observed adult #1 has been residing at the home and Licensee failed to obtain a California clearance and/or a criminal record exemption as required by the Department for adult #1 (licensee’s daughter's partner). In addition, LPA reviewed staff files and obtained documentation related to the case management. Furthermore, LPA completed a safety inspection of the home.

Facility has been cited a Type A citation. Please see LIC809-D. An immediate $500 civil penalty will be accessed.

Upon receipt of a Type A deficiency, 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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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 08/11/2023 03:04 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: CHANG FAMILY DAY CARE
FACILITY NUMBER: 197402255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
102370(d)(1)

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102370 Criminal Record Clearance (d)(1) All individuals...shall prior to working, residing, or volunteering in a licensed facility...Obtain a California clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by:
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LIcensee will ensure uncleared Adult #1 is off of the homes property and ensure that uncleared Adult #1 does not come on the homes property until fingerprinted, cleared and associated to the facility.
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Based on observation uncleared Adult #1 accesses the homes back door when children are present during the hours of operation, which poses an immediate Health, Safety or Personal Rights risk to 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 KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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