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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360904386
Report Date: 04/14/2023
Date Signed: 04/14/2023 12:38:00 PM


Document Has Been Signed on 04/14/2023 12:38 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:LAKE ARROWHEAD COOPERATIVE PRESCHOOLFACILITY NUMBER:
360904386
ADMINISTRATOR:JODY AUTENFACILITY TYPE:
850
ADDRESS:351 N. STATE HIGHWAY 173TELEPHONE:
(909) 337-8686
CITY:LAKE ARROWHEADSTATE: CAZIP CODE:
92352
CAPACITY:24CENSUS: 7DATE:
04/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Jody AutenTIME COMPLETED:
12:45 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 April 14, 2023 at 09:15 a.m., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced Annual Required Inspection. and met with Administrator Jody Auten. LPA disclosed the purpose of the inspection and was granted entry into the facility by Administrator. Seven (7) children, one (1) staff member and one (1) parent volunteer were present at the facility during the inspection. The facility is located on the grounds of Lake Arrowhead Community Presbyterian Church. Center occupies one (1) classroom, one (1) bathroom, kitchen, gym and outside play yard. The hours of operation: 9:00 a.m. to 12:00 p.m. Monday to Friday. September through end of May. Administrator accompanied LPA inside the facility during this inspection.
At 9:33 a.m. LPA and Administrator toured the Center.
Indoor/Children's Area: Child care center was observed to be clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean. Cleaning compounds were stored in a cabinet equipped with child safety lock in the kitchen and on a high inaccessible shelf in the staff office. Therefore, the cleaning products were inaccessible to the children in care. Zero poisons are stored in the classroom. LPA observed the furniture/equipment is in good condition. Classroom was free of flies, other insects, rodents. The classroom tables and chairs and various equipment to meet children’s needs. LPA observed the classroom had designated areas for dramatic play, a library, and a carpet area for story time/instructional area. Children's belongings are kept in cubbies labeled with the children's names. Trash cans for solid waste have tight fitting lids. Drinking water is readily available indoors via a drinking fountain and water bottles provided by the parents/authorized representatives. All materials and surfaces are toxic free, window screens in good repair and free of debris. There is a working carbon monoxide detector, smoke detector and two Fire Extinguisher which were serviced in 2022. There is one bathroom located in the hallway outside of the classroom. The bathroom had two toilets and one sink. Toilets and sinks are functioning properly and are age appropriate. LPA observed soap, toilet paper and paper towels readily available. Report continued on page two
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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 7


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: LAKE ARROWHEAD COOPERATIVE PRESCHOOL
FACILITY NUMBER: 360904386
VISIT DATE: 04/14/2023
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
Report continued from page one

There was working telephone service within the classroom. There is an isolation area for children who become ill. The isolation area is located within the classroom. The facility maintains a comfortable temperature at all times. LPA observed the centers sign in/out sheets, which are completed daily. Smoking is prohibited on the premises. Teacher conducts daily inspection for illnesses. LPA did not observe prohibited childcare items during this inspection. Firearms/weapons are not allowed or stored on premises. LPA did not observe bodies of water on the premises. Meals (one snack) is provided by the parents.

Napping
The preschool program only offers a half day program. Therefore, the children do not nap at the facility. The classroom has a designated areas for relaxation and quite play.

Outdoor
LPA observed the outside play yard is located across a parking lot. According to conversation with Administrator the staff escort and ensure children reach the outdoor activity space safely. During this inspection, LPA was unable to observed the outdoor play space as it was covered in snow. Per conversation with Administrator, the play space is fully enclosed with a fence. Administrator shared there is a climbing structure which is placed on wood chips. LPA observed the fence has sustained damage due to the winter storm. Therefore at this time the outdoor space is not being utilized and the gym is being utilized for large motor activities. LPA advised the Center to submit a unusual Incident Report (UIR) and report the damage to the Department.

Health Related Services
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Report continued on page three
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/14/2023 12:38 PM - 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: LAKE ARROWHEAD COOPERATIVE PRESCHOOL
FACILITY NUMBER: 360904386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above when zero documentation was provided that showed the center had its drinking water tested for lead between 1/1/20 and 1/1/23. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
1
2
3
4
Per Administrator, the facility follow up on the lead testing requirements. Documentation will be submitted to the Department
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in four of seven child files reviewed did not have the written medical assessment on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
1
2
3
4
Per Administrator, parents will be contacted to have the medical assessment completed. Medical Assessment will be added to child files. A checklist will be utilized to ensure files contain all required information.
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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 04/14/2023 12:38 PM - 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: LAKE ARROWHEAD COOPERATIVE PRESCHOOL
FACILITY NUMBER: 360904386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in five of seven child files reviewed were missing required documents and therefore were not complete records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
1
2
3
4
Per Administrator, parents will be contacted to update files with missing documentation. Documents will be added to the child files. A checklist will be utilized to ensure files contain all required information.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


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: LAKE ARROWHEAD COOPERATIVE PRESCHOOL
FACILITY NUMBER: 360904386
VISIT DATE: 04/14/2023
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
Report continued from page two

Child Records
LPA reviewed seven child records during this inspection. Four of seven child files reviewed were missing the medical assessment (LIC 701). (Child #1, Child #2, Child #4, Child #5). Five of Seven child files were missing the LIC 995. (Child #1, Child #2, Child #3, Child #4, Child #5) . In addition, one file (Child #5) was missing the LIC 627, and 700. Based on LPAs record review two type B citations were issued for the child files.

Facility Records


LPA and facility representative reviewed the LIC 311A Records To Be Maintained At The Facility. LPA observed a current roster, however observed the roster was missing information regarding physicians name and phone number. LPA advised the administrator to ensure the facility roster contains all required information. LPA observed the disaster drill log (conducted April 2023).

LPA and Administrator discussed the required Lead Testing requirements. Per conversation with the Administrator the Lead testing may have been completed a few years ago. LPA requested documentation of the Lead testing however zero documentation was at the facility showing the Lead testing requirement was met. Therefore a type B citation was issued.

Posting Requirements
The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393), menu, car seat law (PUB 269), emergency disaster plan, earthquake preparedness checklist. LPA reminded the center representative that failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Other: Electrical outlets are inaccessible, there are no recalled and or prohibited toys or sleep/play equipment observed on the premises. Window cords were inaccessible to children.

Report continued on page four

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: LAKE ARROWHEAD COOPERATIVE PRESCHOOL
FACILITY NUMBER: 360904386
VISIT DATE: 04/14/2023
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
Report continued from page three

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Center shall permit the Department to inspect the child care center and to privately interview children or staff, to determine compliance with or to prevent violations of child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

Facility representative was advised of the requirement to report Unusual Incidents. Facility representative informed to utilize the Unusual Incident Report/Injury Report LIC624 when submitting the report to the department (email www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The On-Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.



Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.



To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: LAKE ARROWHEAD COOPERATIVE PRESCHOOL
FACILITY NUMBER: 360904386
VISIT DATE: 04/14/2023
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
Report continued from page four

Three type B deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

LPA was unable to review the staff/volunteer files during this inspection. Therefore LPA will return on a future date to review the files.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative Jody Auten

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7