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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910831
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:29:39 PM


Document Has Been Signed on 09/25/2024 12:29 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 CC RO, 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: 36DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Magdalena Lozano- Acting site supervisorTIME COMPLETED:
12:40 PM
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On September 25th 2024, at 10:00 a.m., Licensing Program Analysts (LPA) Braddock met with the facility representative, Magdalena Lozano who granted access to the facility. The purpose of the inspection was to conduct an unannounced case management inspection for a UIR received at Palmdale RO on 9/24/24. LPA disclosed the purpose of the inspection to the facility representative. When LPA arrived at the facility there were 36 children in care with 8 staff. The hours of operation for the program are Monday through Friday 7:30 am to 430 pm.

During the inspection LPA obtained a roster of children present on the day of the incident and interviewed staff present and attempted to interview child involved.

LPA completed a safety inspection of the facility at approximately 11:06 a.m.
Based on interviews, Further investigation is required.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the facility representative.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR NAME: Sherell BraddockTELEPHONE: (661) 202-3412
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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