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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409137
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:29:49 PM


Document Has Been Signed on 10/26/2023 03:29 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:NOTRE DAME INFANT CENTERFACILITY NUMBER:
197409137
ADMINISTRATOR:ANGELICA RODRIGUEZFACILITY TYPE:
830
ADDRESS:21704 GOLDEN TRIANGLE RD.#120TELEPHONE:
(661) 255-0053
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:30CENSUS: 23DATE:
10/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Angelica Rodriguez, DirectorTIME COMPLETED:
04:00 PM
NARRATIVE
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On Thursday, October 26, 2023 Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced case management inspection and met with Director Angelica Rodriguez. During this visit, LPA Rivera reviewed staff and children files and observed the files to be incomplete. LPA informed 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, staff missing LIC 503 Health Screening Report, and staff missing AB 1207 Child Abuse Mandated Reporter Certificate and toddlers missing permission from the child's authorized representative for the placement of the child in the toddler program.

During the visit LPA Rivera explained the citations and technical violations with director Angelica and director provided the plan of correction. Due date November 24, 2023.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, during which this report and the Appeal Rights were discussed with Director Angelica Rodriguez.


SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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 10/26/2023 03:29 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: NOTRE DAME INFANT CENTER
FACILITY NUMBER: 197409137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2023
Section Cited
HSC
1596.7995

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Employees or volunteers at day care center; immunization requirements; records; exemptions. (a) (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
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Director Angelica stated she is going to let the staff know within this week what is needed and give staff a deadline before due date.
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influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. Based on record review, the licensee did not comply with the section cited above in not having staff provide immunization record which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/24/2023
Section Cited
CCR101417

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Toddler Component in an Infant Care Center
(a) Licensees serving infants may create a special program component for children who are between 18 months and 36 months of age. . (1) The infant care center shall obtain written permission from the child's authorized representative for the placement of the child in the toddler program.
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Director Angelica stated she is going to create the Toddler Permission Document and have parents review and sign by due date.
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 the licensee did not comply with the section cited above in not obtaining written permission from the child's authorized representative for the placement to toddler program which poses a potential health, safety or personal rights risk to persons 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: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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