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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360904386
Report Date: 04/24/2023
Date Signed: 04/24/2023 10:46:33 AM

Document Has Been Signed on 04/24/2023 10:46 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
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: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 7DATE:
04/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Jody AutenTIME COMPLETED:
11:00 AM
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On April 24, 2023 at 09:25 a.m., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced Case Management Annual Continuation inspection and met with Administrator Jody Auten. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. Seven (7) children, the Administrator and one (1) parent volunteer were present at the facility during the inspection.

During this inspection LPA reviewed two staff file. Per LPA's record review and interviews, the Parent volunteer files and the Administrators file did not contain documentation of the required immunization's. An advisory notice was issued to the Center.

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.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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