<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700110
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:56:26 PM


Document Has Been Signed on 10/01/2024 02:56 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
CCLD Regional Office, 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: 1DATE:
10/01/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Mercedes Duobert-Chumbe, Licensee TIME COMPLETED:
03:20 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 10/01/24, Licensing Program Analyst (LPA) Justeene Tamayo conducted an unannounced annual inspection and met with licensee, Mercedes Duobert-Chumbe who guided LPA on a tour of the facility. This is a two story home with 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.Family members residing in the home include 2 adults (Licensee and Licensee's Spouse) and no minor children. LPA observed 1 preschool age child present in the home with Licensee and assistant #1 caring for them. Operating hours are Monday to Sunday, 24 hours a day as needed.

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

LPA Tamayo inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Tamayo 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 Tamayo observed cleaning compounds items, stored in the upper kitchen 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. Medication is stored in the upper kitchen cabinet with a master lock. Per licensee, breakfast, lunch, snacks, and dinner 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.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 10/01/2024
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
26
27
28
29
30
31
32
Bathroom: LPA Tamayo observed the toilet, hand washing sink, hand soap in the child care bathroom. The bottom sink cabinet did not have any accessible hazardous materials observed. The child care bathroom observed to be in good condition. LPA reminded licensee, personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Tamayo 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 and observed to be in operable condition. 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. Last Fire/Disaster drill was completed on 08/19/2024.



Outdoor: Children play in the back yard. LPA 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 a jungle gym anchored and in safe condition. There is also an empty koi pond in the back yard. The empty pond is surrounded by chain link fence (declaration in file).Per licensee, there are 3 dogs in the home. Licensee stated there are no guns, weapons, or firearms in the home.

Licensee's First Aid/CPR expires on 04/18/2026. Licensee's mandated reporter training expires on 06/18/2026.

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.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 10/01/2024
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
26
27
28
29
30
31
32
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.

No deficiencies have been cited at this time.

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, along with a copy of her appeal rights.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3