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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910831
Report Date: 06/30/2022
Date Signed: 06/30/2022 12:41:06 PM


Document Has Been Signed on 06/30/2022 12:41 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: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: 0DATE:
06/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Linda WalkerTIME COMPLETED:
01:00 PM
NARRATIVE
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On 06/30/2022, Licensing Program Analyst (LPA), Babatunde Ibitoye arrived at the facility to conclude the Unusual Incident investigation that was reported to the department on 5/12/22. LPA disclosed the purpose of the visit and was granted entry into the facility by the Site supervisor, Linda Walker.

During the investigation, LPA Ibitoye conducted interviews with the Site supervisor, and all parties involved. The interviews revealed consistencies in the explanations that on 5/12/22 an incident was reported that child #1 ran out the front door of the facility. Staff #1 ran behind child #1 and returned C1 back to the school.

Based on the interviews conducted, it was revealed the incident occurred on 5/12/22 and the facility failed to report the incident to the department until 5/18/22. It was also revealed that the facility failed to report the incident to the child ‘s authorized representative in a timely manner. There is a preponderance of the evidence to prove that a violation occurred, Therefore, the facility will be cited for Reporting Requirements. Deficiency Cited: See LIC 809D

Exit interview conducted: A copy of the report and appeal rights were discussed and left with the Site Supervisor Linda Walker.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Babatunde IbitoyeTELEPHONE: 661-568-8179
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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Document Has Been Signed on 06/30/2022 12:41 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: PSD/APPLE VALLEY HEAD START
FACILITY NUMBER: 360910831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited

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Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement was not met as evidenced by an unusual incident report concerning the incident that occurred on 05/12/22 was not reported to the department CCLP and C1’s parent in a timely manner. This is a type B deficiency, that if not corrected, 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: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Babatunde IbitoyeTELEPHONE: 661-568-8179
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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