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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493368
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:17:06 PM


Document Has Been Signed on 03/14/2024 04:17 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 FAMILY SERVICESFACILITY NUMBER:
197493368
ADMINISTRATOR:RODRIGUEZ, ANGELICAFACILITY TYPE:
840
ADDRESS:21706 W. TRIANGLE ROADTELEPHONE:
(661) 255-0053
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:30CENSUS: 18DATE:
03/14/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Angelica Rodriguez, DirectorTIME COMPLETED:
04:46 PM
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On Thursday, March 14, 2024, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with director Angelica Rodriguez who granted access and guided LPA Rivera on a tour of the facility.

This is a school age program that serves children ages 5 to 12 years. This program operates Monday to Friday 7:00 a.m. – 6:00 p.m. Staff sign in and parents sign out. Teacher and child ratio were observed, and present staff are fingerprinted cleared and at least one person present who is trained in pediatric first aid/CPR is present. At approximately 2:30 p.m., 15 school-age children arrived and approximately 3:20 p.m., 3 school-age children arrived.



At approximately 2:55 pm, LPA Rivera entered classroom School Age 2 and observed 15 school age children with staff #1, and staff #2. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside a blue top cabinet located in the bathroom. LPA also observed a trash bin with a lid.

At approximately 3:14 pm, LPA Rivera entered classroom School Age 1 and observed no children. LPA observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside a blue top cabinet located in the bathroom. LPA also observed a trash bin with a lid.

LPA Rivera observed 2 individual bathrooms located in School-Age 2 classroom and one bathroom in School Age 1 classroom. LPA observed 3 toilets and 3 handwashing sinks. LPA observed the bathrooms to be in good condition and free from hazards.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: NOTRE DAME FAMILY SERVICES
FACILITY NUMBER: 197493368
VISIT DATE: 03/14/2024
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Heating, lighting, and ventilation were evaluated by LPA Rivera. LPA observed central AC /heater and vents located on the ceiling. LPA observed the thermostat located in the hallway and the temperature to be at 70. LPA observed the fire extinguishers located in the hallways and the classroom and observed the valve on the required 2A10BC fire extinguishers indicating fully charged and serviced on 8/9/2023. Smoke detectors were not tested during this visit due to the detectors being wired to the emergency pull down fire alarm system. The carbon monoxide detector is in the nap room and LPA Rivera tested and heard the sound and is operable. The last emergency drill was conducted on 11/14/2023.

First aid kits supplies are kept inside the classrooms and LPA observed the kits to be fully equipped with band aids, gauzes, adhesive bandages, and antiseptic wipes. During this visit, director Angelica stated currently has one child with medication and severe food allergies. LPA observed the medication EPI PEN with expiration date 10/31/2024 and liquid allergy medication with expiration date 6/2025. LPA Rivera asked if there were any poisons, firearms, weapons, or bodies of water. The director stated no firearms, weapons, no poisons nor bodies of water. LPA did not observe firearms or weapons, poisons, nor bodies of water. Director stated the ill isolation area takes place in the director’s office and children utilize the staff restroom. Lead testing was conducted on 2/17/2023 and no lead exceedance.

At approximately 3:24 p.m. LPA Rivera entered the outdoor play area. LPA Rivera observed the playground to be fenced all around and the wooden gate closed and locked with a self-latch. LPA Rivera observed the equipment to be in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera observed play structure equipment to be age appropriate and areas around or under climbing equipment, are cushioned with artificial turf that may absorb a fall. For adequate shade, LPA Rivera observed 1 hip roof shade structure. LPA observed a trash bin with a lid. For outdoor water drinking, children bring out water their water hydro flask and staff water pitcher. Facility provides transportation. LPA observed the transportation vans with child booster seats. LPA observed two water heaters located outside. One water heater temperature is at 120 and the other one reads hot.

This program provides snacks and meals parents have an option to provide the meals. If parents forget to bring the meal, director stated, facility will provide the meal. LPA Rivera informed director Angelica that any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. For water drinking, LPA Rivera observed water pitchers, and their water bottles in the

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: NOTRE DAME FAMILY SERVICES
FACILITY NUMBER: 197493368
VISIT DATE: 03/14/2024
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classrooms. LPA observed the food preparation area to be clean and free of litter, rubbish, rodents, and/or any other vermin and storage containers for solid waste, including movable bins with tight-fitting covers that are kept on, and in good repair. The facility was observed to be free of flies, other insects and rodents.

The following documents were posted in a prominent, publicly area front lobby: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), Menu, and PUB 269 Child Passenger System Poster, and Daily Schedule.

LPA Rivera reviewed the children’s roster, children’s files, staff files, and sign in/out sheets and observed 18 signed in signatures.

LPA Rivera observed director Angelica Rodriguez Pediatric First Aid/CPR certification from American Red Cross dated 1/16/2023, Preventative Health and Safety with nutrition and lead component dated 7/15/2023-7/16/2023 and has proof of immunization against Pertussis, MMR and Influenza declination. Director has completed the mandated reporter (AB 1207) training dated 3/25/2023. Director was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com



The following was also discussed with director:
1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Breakfast/Lunch/Snack Menus: Menus are required to be posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days must also be available upon request.

3. Current Children’s Roster: Each childcare facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: NOTRE DAME FAMILY SERVICES
FACILITY NUMBER: 197493368
VISIT DATE: 03/14/2024
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4.LIC 125 Entrance Checklist provided, and LPA informed that forms, regulations and quarterly updates can be accessed on the Child Care Licensing website at: www.ccld.ca.gov.

5.Pediatric First Aid and CPR: At least one person trained in Pediatric First Aid and CPR and EMSA approved must be present.

6.Designated Staff: The name of the childcare center director or fully qualified teacher(s) designated to act in the director's absence must be on file.

7.Qualifications: Educational background, training, and/or experience for each staff present must be available for review.

8. Immunization Requirements: 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 or influenza declination

9.Children’s Records: must be available for review; including but not limited to, the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

10. Staff Records: must be available for review; background clearance, LIC 503 Health Screening report, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse, Staff Qualifications, LIC 9050 Employee Rights, LIC 501 Personnel Record, AB 1207 Mandated Child Abuse Certification, MMR, TDAP, TB, influenza or influenza declination.

Director Angelica Rodriguez was reminded that all adults 18 and over, 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 Child Care Center. 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.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: NOTRE DAME FAMILY SERVICES
FACILITY NUMBER: 197493368
VISIT DATE: 03/14/2024
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA Rivera discussed the safe sleep regulations with director Angelica Rodriguez and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Angelica Rodriguez 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Director Angelica Rodriguez formed 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.

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-care-licensing/inspection-process.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: NOTRE DAME FAMILY SERVICES
FACILITY NUMBER: 197493368
VISIT DATE: 03/14/2024
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This visit there were no deficiencies. A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview conducted and report was reviewed with director Angelica Rodriguez.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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