197416481-9-21-2022-12-CC-BBEO-CJGU2B-20220921151139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197416481
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:12:36 PM

Document Has Been Signed on 09/21/2022 03:12 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:	SHIRLEY FAMILY CHILD CARE		FACILITY NUMBER:	197416481
ADMINISTRATOR:	SHIRLEY, KIMBERLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 904-7211
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY:	14	CENSUS:	DATE:	09/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:58 PM
MET WITH:	Kimberly Shirley		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/21/2022 Licensing Program Analysts (LPA) Barbara Beneroso, met with assistant Jasmine Barila, who guided analyst on a tour of the facility for the One Year Required inspection. Licensee arrived shortly after. This is a two story home with 4 bedrooms, 2 bathrooms. The second story is completely off limits to day care children. Child proof gate was observed at the staircase. The backyard is completely fenced in; there is a pool that was observed to be made inaccessible by a mesh fencing that is five foot high with a gate that is self latching, self closing and opens away from the pool. Upon arrival LPAs observed 7 children in care and 3 adults caring for them. Family members residing in the home include 3 adults (licensee, licensee's adult children ) and 1 minor child. Facility operation hours are Monday - Friday 7AM- 5 PM. Incidental Medical Services (IMS) policy was discussed. Physical Plant: Main care is provided in the living room. The children use the bathroom located down the hallway to left. The off-limits areas are all three bedrooms upstairs, bedroom downstairs, second restroom (upstairs) and kitchen. Laundry room and garage are also off limits locked. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under kitchen sink with child lock), medicines are kept in the upper cabinet and hazardous items (sharp knives located in garage) LPA observed the fireplace to have a screen and locked with child safe lock. Safe and age appropriate toys, play equipment and materials were observed. The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) is in operable condition. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the kitchen. Per Licensee, there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Barbara Beneroso	TELEPHONE: (661) 202-3411
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 09/21/2022

NARRATIVE

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Fire/Disaster drills are maintained current. Last fire/disaster drills was completed on 09/21/2022.

Bathroom: LPA did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are located in the kitchen (under sink with child lock). Breakfast, lunch, snacks are provided. Licensee stated she currently does not have a food program. Naps are provided on cots and mats in the living room (child care area)

Outdoor: The front yard is off limits. The backyard is completely fenced in; there is a pool that was observed to be made inaccessible by a mesh fencing that is over five foot high with a gate that is self latching, self closing and opens away from the pool. LPA observed age appropriate toys, as well as a storage shed with arts and crafts materials. LPA observed one dog on the premises.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expired 09/07/2019. Mandated Reporter expired on 09/06/2018. Licensee will complete the mandated reporter training at www.mandatedreporterca.com and submit proof of CPR/First aid via email it to LPA Beneroso for proof of completion by 09/23/2022. LPA reminded licensee, mandated reporter training must be completed every 2 years.

Documents Provided and or Discussed: Fire Drill Log, Postings, Employee's and Children's records, Safe Sleep PIN 20-24-CCP and Individual Sleeping Plan (LIC9227). Licensee currently does not have child care insurance.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Barbara Beneroso	TELEPHONE: (661) 202-3411
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SHIRLEY FAMILY CHILD CARE	FACILITY NUMBER: 197416481
	VISIT DATE: 09/21/2022

NARRATIVE

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Licensee Shirley was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

LPA discussed the safe sleep regulations with licensee Shirley and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Shirley along with her appeal rights.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Barbara Beneroso	TELEPHONE: (661) 202-3411
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

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