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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700110
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:21:26 PM


Document Has Been Signed on 11/30/2023 03:21 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:DUOBERT-CHUMBE FAMILY CHILD CAREFACILITY NUMBER:
197700110
ADMINISTRATOR:DUOBERT-CHUMBEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 478-8581
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:14CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Mercedes Doubert-ChumbeTIME COMPLETED:
03:45 PM
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On November 30, 2023, Licensing Program Analyst (LPA) Annelise Villa conducted an unannounced annual inspection and met with licensee, Mercedes Duobert-Chumbe who guided LPA Villa on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. LPA observed 4 preschool age children present in the home with Licensee and 1 staff member caring for them. Operating hours are Monday to Sunday, 24 hours a day as needed.

4 bedrooms, 3 bathrooms, a kitchen, a family room, a living room/dining room, a den, a laundry room, a garage, and a backyard. The garage is used for storage only and no childcare activities are conducted there.

Areas off limits to children include- Bedrooms #2-4, bathrooms #2-3, all upstairs spaces, garage, laundry room, and front yard.

LPA Villa inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Villa observed central AC and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA did not observe any fire places in the home.

LPA Villa observed cleaning compounds items, stored in the pantry, which has a door with operable safety. LPA observed the knives/sharp objects and medications in upper kitchen cabinets, out of reach to children in care. Per licensee, breakfast, lunch, and snacks are provided. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any children with severe food allergies nor on medication. Licensee is a participant in a food program.

Continued on LIC 809-C

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/30/2023
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LPA Villa entered the bathroom #1 and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe any accessible hazardous materials and observed the restroom to be in good condition. LPA reminded licensee and personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Villa asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. Per licensee, there are 3 dogs in the home. Licensee stated there are no guns, weapons, or firearms in the home. LPA observed one empty fish pond in the back yard. The license was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition must be stored separately.

LPA Villa observed the required 2A10BC fire extinguisher located outside of bedroom #1 and the valve on the green area indicating fully charged. LPA observed a carbon monoxide detector and smoke alarm located in the living/family room. LPA tested the carbon monoxide and smoke alarm by pressing the test buttons on each. LPA Villa heard the sounds and confirmed both detectors are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located outside of bedroom #1. There is an isolation area for children who become ill while in care as needed. LPA observed the last emergency drill conducted on 11/30/2023.



Outdoor: Children play in the back yard. LPAs toured the porch and observed it to be free of garden tools, poisonous plants, thorn trees, cactus, or lawn mower inaccessible to children. The play area is clear and clean of debris, play area is fenced and gated all around. LPA observed age-appropriate play equipment for children. There is an empty koi pond in the back yard. The pond is surrounded by a 5 foot chain link fence.

LPA Villa observed licensee Red Cross Pediatric First Aid/ CPR certification dated 2/25/2022 and licensee has proof of immunization against Pertussis, MMR, and Influenza declination. Licensee has completed the Child Abuse Mandated Reporter (AB 1207) training dated 2/17/2022. Licensee was advised that the mandated reporter training must be completed every 2 years and is available at www.mandatedreporterca.com.
LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, LIC 610A Emergency Disaster Plan, Pub 394 Notification of Parents Rights, and LIC 999 Facility sketch. LPA also reviewed children’s roster, children files including sleep logs and staff files. LPA observed the files to be complete.

Continued on LIC 809-C

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/30/2023
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The following was also discussed with the licensee:

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 Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present.

3. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

4. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

5. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

6. The fire extinguisher must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

7. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

8. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B). Mandated reporter requirements were reviewed and explained.

Continued on LIC 809-C

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/30/2023
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9. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

10. Smoking is prohibited in the family childcare home.



11. Children and staff records must be maintained and updated as needed and be available for review by the Department.

12. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

13. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



14. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

15. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

16. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

17. Dog(s) and/or pets are recommended to be isolated from children in care.

18. No baby bouncers, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.



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.

Continued on LIC 809-C
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 11/30/2023
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Criminal Record Clearance - Family Child Care Homes Licensee 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.

Safe Sleep - Child Care Centers and Family Child Care Homes LPA discussed the safe sleep regulations with licensee 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 [or facility representative] 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, 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/.

Licensee was informed of the www.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.

Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted, and report was reviewed with the licensee Mercedes Duobert-Chumbe.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Annelise VillaTELEPHONE: 661-202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5