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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910831
Report Date: 05/03/2019
Date Signed: 05/03/2019 02:36:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:PSD/APPLE VALLEY HEAD STARTFACILITY NUMBER:
360910831
ADMINISTRATOR:DOLORES EDWARDSFACILITY TYPE:
850
ADDRESS:13589 NAVAJO ROADTELEPHONE:
(760) 247-6955
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:117CENSUS: DATE:
05/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Dolores EdwardsTIME COMPLETED:
02:49 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claretta Yates an unannounced inspection at the above facility and met with Center Director Delores Edwards at the Apple Valley Head Start. The purpose of the visit was to conduct a Case Management -Incident regarding an Unusual Incident/Injury Report (UIR) submitted to the Palmdale Child Care Office on 03/14/19. The UIR alleged Teacher #1 pulled Child #1 by the arm. (See Confidential Names List LIC 811) dated 05/03/19

LPA Yates investigated the incident and was informed that C1 sustained noticeable bruises on the arm (Photos taken).

The investigation consisted of interviews with staff, the alleged victim and Teacher #1 and a review of supportive documents. Based on the interviews regarding the UIR, it appears that Teacher #1 violated C1 Personal Rights. Therefore the facility is being cited for a Personal Right violation The facility was cited an $500.00 Immediate Civil Penalty due to child sustaining injuries.

Deficiency cited: See LIC 809D

Exit interview conducted: A copy of this report, appeal rights and notice of site inspection was discussed and left with Center Director Dolores Edwards.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Claretta YatesTELEPHONE: (661) 568-8081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
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
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: PSD/APPLE VALLEY HEAD START
FACILITY NUMBER: 360910831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2019
Section Cited
CCR
102423(a)(1)
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Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: To be treated with dignity in his/her personal relationship with staff and other persons.
To be free from corporal or unusual punishment,
infliction of pain, humiliation, intimidation,
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Center Director states the facility will conduct a Daily Health Check to each child upon arrival to the facility. The Center Director will provide proof of All staff training on Supervising Children by 05/17/19.
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, This requirement was not met as evidenced by: LPA observations, interviews and photo Teacher #1 pulled C1 by the arm. This poses a potential risk to the health and safety of children in care.
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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: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Claretta YatesTELEPHONE: (661) 568-8081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
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