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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492761
Report Date: 03/13/2024
Date Signed: 03/13/2024 11:03:07 AM


Document Has Been Signed on 03/13/2024 11:03 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:SHELLEY FAMILY CHILD CAREFACILITY NUMBER:
197492761
ADMINISTRATOR:SHELLEY, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 878-1429
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:14CENSUS: 2DATE:
03/13/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Nicoe ShelleyTIME COMPLETED:
11:15 AM
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On 3/13/2024, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 3-Year inspection at the Shelley Family Child Care. Upon arrival, the LPA met with the licensee, Nicole Shelley, who guided the LPA on a facility tour. Individuals that reside in the home include 2 adults (licensee and licensee’s husband) and 3 children (age: 11, 13, 2 years old ). During this inspection, there are one (1) childcare child (1 yrs and 11 months) and the licensee’s daughter (almost 3) with the licensee. Per the licensee, the hours of operation are Monday through Friday, 24 hours. Incidental Medical Services (IMS) were discussed. Per the licensee, she does not have children who need IMS.
The home is set up as follows:
This is a one-story, three-bedroom, two-bathroom home with a kitchen/dining room, living room, back den room, laundry room, and garage. There is no pool/spa or body of water on the premises. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The house has central heating and air conditioning. All windows have screens free of cracks, bugs, and debris.

Main Area: Main care is provided in the back den area and Living room. Children use the bathroom in the hallway on the right. They have access to the den area (children's playroom) and backyard. Off-limit areas include all bedrooms, bathroom #2, the laundry room, and the garage.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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Kitchen/Dining Room: The kitchen was inspected to ensure hazardous and dangerous items were inaccessible to children. Sharp utensils, poisons, and medications are available to children in the kitchen. LPA observed knifes are in the kitchen draws without a safety latch. Medications are behind the kitchen sink. LPA observed safety gate barricading the kitchen and hallway to the laundry room and off-limit bedrooms.

Children's bathroom (#1): Bathroom: Children will use the bathroom down the hall to the right. The bathroom was toured and inspected, and the sink/toilet is in operable condition. Toilet and faucets are clean, safe, and operable. LPA observed poison and medications are accessible to children without child safety latches on the sink cabinet. There are some contains in front of the children bathroom with many personal items and accessible to the childcare children.

Back den area (Off-limit) Declaration : According to the licensee, she only has 1 childcare child. No children is use the back den area ( the designated childcare areas). LPA observed age-appropriate toys and furniture for the children and many personal materials. In the family room, additional toys were observed to be stored in cubbies.

Backyard (off-limit) Declaration: LPA observed the backyard; According to the licensee, the backyard is no being used for a while. LPA observed 3 dogs in the backyard. The backyard is completely fenced (with a wooden gate). LPA observed several wooden fences need repair. There is no body of water. LPA reminded the licensee to pick up dog feces before children have access to the backyard area for playtime.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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Others:
AC/Heating Unit was observed. The AC/Heating Unit is located on the right side of the home and is inaccessible to children via barrels blocking access to the unit. / The swamp cooler unit is inaccessible to children.
Bodies of water: Per the licensee, there are no bodies of water in the home, but there is a decorative water fountain that does not have water.
Electrical outlets: All unused electrical outlets will need to plugg in with covers and made inaccessible to children.
Fire extinguisher (2A10BC): LPA observed a required fire extinguisher (2A10BC) reading in Green, located in the playroom, and inaccessible to children. According to the licensee, she had the service in 2022.
Fireplace: In the family room, a fireplace was observed that was properly screened via mirror glass doors. The fireplace is inaccessible to children.
Hanging window blind cords: The cords are inaccessible to children.
Isolation area (Illness): Per the licensee, if the child shows signs of illness, they will be separated from other children and stay in Family room
Medications and cleaning solutions: Detergents/cleaning compounds are in the upper kitchen cabinet without a safety latch. Medications are in behind kitchen sink.
Napping: Children will nap in the designated nap areas with adult supervision. LPA observed 2 cots in the closet.
Overnight Care: According to the licensee, it does not provide overnight care.
Pets: There are three small dogs (backyard). The licensee will email the current vaccinations to LPA.
Phone service: There is a working landline or cell phone
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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Smoke Detectors and Carbon Monoxide: The licensee was unable to test the smoke detectors and carbon monoxide devices due to no battery.
The First Aid kit is in the key-locked closet, inaccessible to children. The First Aid Kit was observed to be complete with supplies. LPA did not observe the first aid manual.
Transportation: The licensee does NOT provide transportation for children.
Weapons or Firearms: Per the licensee, there are No Firearms at the facility at this time. LPA does not observe any firearms.
Documentation:
Child files: LPA reviewed 1 child's records. The records are incomplete and missing Immunization record.
Infant Sleeping Plan (LIC 9227) and Sleeping Log: There is 1 infant enrolled in the facility. The licensee does not have LIC 9227 and Sleeping log in the files. LPA shared the Safe Sleeping Regulation with the licensee.
Immunization: The licensee has the required immunizations (MMR and DTaP). The licensee provided a written statement declining the influenza vaccination.
CPR/First Aid: LPA observed that the licensee has current Pediatric CPR and First Aid Training with an expiration date (of 04/2024) 1 hour of nutrition training and (8) hours of Preventive Health and Safety Training.
Mandated Reporter Training: During today’s inspection, the licensee was unable to find her Mandated Reporter training certificate.
Facility fees: Per the Licensing Information System, annual facility fees were current.
Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and conducted on 01/2024.
Parent Board: LPA observed the licensee does not post Earthquake Preparedness.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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The following information was discussed with the licensee:
o A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code sections 1596.848(b) and (c). State law prohibits baby walkers, bouncy seats, exersaucer, and other items that fall into that category.
o Capacity requirements, Roster requirements, Posting requirements, and Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children's and provider's files and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. The licensee was reminded that supervision is always required for children in care.
o The licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
o Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations. Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. The licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility's phone number; if the phone number is changed, licensing must be notified.
o Mandatory Forms for the children's files and provider's files.
o Our Quarterly updates come out every 3 months. They are also now in Spanish. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
o Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 5 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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o Requirements for fire drills, earthquake drills, and documentation for both.
o The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 a.m. - 5:00 p.m.
o The licensee is reminded that 100% supervision is required for children at all times.
o The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
o The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family childcare home where children are present (24/7 ban).
· Family Child Care Homes Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
· To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-carelicensing/ inspection-process.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 6 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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 IF THERE IS NO CHILD AT THE FACILITY THAT CURRENTLY NEEDS IMS, USE AS FOLLOWS: Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.
· Centers and Family Child Care Homes Licensee [or facility representative] was informed of the MyChildCarePlan.org website, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
· Family Child Care Homes During the exit interview, the LICENSEE ****, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
· Family Child Care Homes A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 7 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761
VISIT DATE: 03/13/2024
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Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.

An exit interview was conducted, and the report was reviewed with the licensee, Nicole Shelley.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 03/13/2024 11:03 AM - 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) and (interview) , the licensee did not comply with the section cited above, the smoke detector did not battery, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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The licensee will get the battery and test the detector to make sure the device is working.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review, the licensee did not comply with the section cited above. LPA review 2 children files, the infant does not have sleeping log since 2022,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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The licensee will use the sleeping log when the infant is sleeping until the infant turns 2 years old.
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: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 9 of 13


Document Has Been Signed on 03/13/2024 11:03 AM - 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: SHELLEY FAMILY CHILD CARE
FACILITY NUMBER: 197492761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. During today's visit, the licensee was unable to provide the certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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The licensee will find the Mandated Reporter training certification and email to LPA nby 3/18/2024
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. The licensee did not have the LIC 9227 for the infant who is enrolled with the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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The licensee will ask the infant's parent to fill out the lIC 9227 and email to LPA by 3/18/2024
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: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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