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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415175
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:09:00 PM


Document Has Been Signed on 04/27/2023 01:09 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:SUNSHINE DAY CAMPFACILITY NUMBER:
197415175
ADMINISTRATOR:GLEESON, RYANFACILITY TYPE:
850
ADDRESS:27630 NEWHALL RANCH ROADTELEPHONE:
(661) 294-1970
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:150CENSUS: 108DATE:
04/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Laura Wehn, Assistant DirectorTIME COMPLETED:
01:45 PM
NARRATIVE
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On April 27, 2023, Licensing Program Analysts (LPAs) Annelise Villa conducted an unannounced case management inspection to follow up on an Unusual Incident that happened on 4/11/2023. Child #1 was was playing on the outdoor playground when they tripped and fell. Ice was immediately applied to the area of pain. Child afterward complained of continued neck pain. Facility notified parent and child was then taken to urgent care. On April 14, 2023, facility was notified Child #1 had broken his collar bone.

LPAs toured the facility and observed 10 preschool classrooms with a total of 108 children. LPA conducted interviews and obtained other supportive documentation related to the unusual incident.

Based on the information gathered and interviews, the Facility did not follow California Code of Regulations (CCR) Section 101212(d)(1)(B), Reporting Requirements. The Facility failed to report an incident which took place on April 11, 2023, within 24 hours. The report was subsequently made on April 17, 2023, via telephone to the Palmdale Regional Office. A Type B deficiency is being cited in accordance with Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to the licensee, along with her appeal rights and Notice of Site Visit.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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 04/27/2023 01:09 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: SUNSHINE DAY CAMP
FACILITY NUMBER: 197415175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2023
Section Cited

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Reporting Requirements. A report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information shall be submitted to the
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Director states that she will report all unusual incidents to the department within 24 hours and provide a written statement within 7 days of an occurrence of any unusual incident. Director will send an unusual incident report for this occurrence.
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Department within seven days following the occurrence of such event. This requirement was not met as evidence by: Staff failed to report an unusual incident on 4/11/23 in which Child #1 fell and broke their collarbone. The facility reported the incident on 4/17/23.
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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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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