360919005-10-24-2023-12-CC-APIN-CWWVFU-20231024162430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360919005
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:24:42 PM

Document Has Been Signed on 10/24/2023 04:24 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:	ULIBARRI FAMILY DAY CARE		FACILITY NUMBER:	360919005
ADMINISTRATOR:	ULIBARRI, NILDA M.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(760) 252-4425
CITY:	BARSTOW	STATE: CA	ZIP CODE:	92311
CAPACITY:	14	CENSUS: 4	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:58 PM
MET WITH:	Licensee Nilda Ulibarri		TIME COMPLETED:	04:35 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 10/24/2023 at 12:58pm, Licensing Program Analyst (LPA) Andrea Pittman conducted an unannounced annual random inspection. The LPA disclosed the purpose of the inspection and was permitted entry by the Licensee. The Licensee guided the LPA on a tour of the home. Upon entry to the facility, the LPA observed 4 children in care and the Licensee providing care and supervision (fingerprint cleared and associated to the home.) The operational childcare hours are Monday through Friday, with every other Friday off, and from 6:00am to 4:30pm. The Licensee updated the LIC 279 Application to reflect a change in capacity, lowering from a Large FCCH to a Small FCCH. This is a one-story family home. There is a living room, family room/dining room, kitchen, three bedrooms, two bathrooms, laundry area, and attached garage but not accessible from inside the home. Licensee does provide napping, there are four playpens and 6 mats. The off-limits areas are the two bedrooms, second bathroom, laundry area, and garage. Licensee provides breakfast, lunch, and snacks. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Hanging window blind cords: The cords are inaccessible to children. Pets: there are three dogs on premises, fully vaccinated. Phone service: There is a working cell phone, charged and kept on the Licensee at all times. Transportation: The Licensee does not provide transportation for children. Knives are kept in the kitchen high above the refrigerator, inaccessible to children in care. Medication is kept in the off-limits bedroom closet, inaccessible to children in care. Cleaning supplies and chemicals are kept in the kitchen in a high cabinet, inaccessible to children in care. Continue to next page

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Andrea Pittman	TELEPHONE: 661-202-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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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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: ULIBARRI FAMILY DAY CARE	FACILITY NUMBER: 360919005
	VISIT DATE: 10/24/2023

NARRATIVE

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There are age-appropriate toys and equipment on the premises. The outdoor area is free from sharp objects, broken toys/furniture & equipment, and other debris. Per the Licensee, there are no weapons, firearms, and ammunition in the facility. The LPA did not observe any weapons. Per the Licensee, there is no smoking on the premises.

The First Aid kit included a temperature thermometer, tweezer, scissors, gauzes, and cleansing pads/solution was observed to be complete and inaccessible to children kept high in the off-limits bedroom. The required fire extinguisher (3A40BC) is reading in green, last tested on 12/28/2022. Smoke and carbon monoxide dual detector was found to be in operable condition, tested at 2:02 p.m. Fire and Disaster drills are conducted at least every six-month, last drills were recorded on 10/24/2023 at 2:07pm for drills.

Licensee had painted and needs to replace onto the wall all of the required posted documents: Facility License (LIC 203,) Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148); the Licensee did have all of the required documents that need to be posted and will repost at the earliest convenience.

Licensee does not have insurance on the family child care home and has the parents complete the LIC 282.

The Licensee provided proof of immunization against pertussis (TDAP), measles (MMR), TB, and statement declining the Influenza for self and TB for Spouse.

Licensee was able to provide a valid CPR/First Aid training valid until 5/2025. Child Care Provider Mandated Reporter Training Certificate has expired, this is a Type B violation, see the LIC 809D for the details. Staff Personnel files were complete with the: Immunizations: MMR, Tdap, TB, & Flu shots/statements declining the Flu shot, background clearances, and Pediatric First Aid & CPR.

Children’s records: files were found to include the following required documents: LIC 700-Identification and Emergency Consent, LIC 627-Consent for Medical Treatment, LIC 995A-Notification of Parent’s Rights, LIC 995E-Caregiver Background Check Process, and LIC 9150- Parent Notification of Additional Children in Care, LIC 9212-Family Child Care Consumer Awareness Information, and PM 286-California School Immunization Record. The Licensee was not aware that she needed to keep a copy of the immunizations and returned the immunizations once the Licensee had completed the PM 286 Form. This is only a technical assistance informing the Licensee of the need to maintain a copy of the immunizations in the children’s records.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Andrea Pittman	TELEPHONE: 661-202-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: ULIBARRI FAMILY DAY CARE	FACILITY NUMBER: 360919005
	VISIT DATE: 10/24/2023

NARRATIVE

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Licensee's facility child roster is current and maintained up to date.
The following were discussed: No smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category which are not permitted in the facility. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files, posting requirements, and penalties.

Facility Representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

The Licensee was reminded to report Unusual Incidents. 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 family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The Licensee was informed to utilize the Unusual Incident Report/Injury Report Form LIC624B when submitting the report to the department.

LPA discussed the safe sleep regulations with the Facility Representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/
safe-sleep as an additional resource. LPA also informed the Facility Representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Provided Licensee with an Infant Sleep Plan form LIC 9227 and the sleep log.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Andrea Pittman	TELEPHONE: 661-202-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: ULIBARRI FAMILY DAY CARE	FACILITY NUMBER: 360919005
	VISIT DATE: 10/24/2023

NARRATIVE

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New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-
CCP. When any IMS is provided, a Plan for Providing 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: https://www.ada.gov/resources/child-care-centers/.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Facility Representative confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Child Care Advocates:
To sign up for our Quarterly Updates please email the Child Care Advocates at
chilcareadvocatesprogram@dss.ca.gov & (916) 654-1541.

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000.

Per Title 22 Regulations, this facility is not in compliance, a Type B Deficiency has been cited. Please, see the LIC 809D for the details.

An exit interview was conducted, a copy of this Report, a Notice of Site visit, and Appeal rights were provided and discussed with the Facility Representative.

All licensing reports are recommended to be kept for 3 years. The Notice of Site visit is to be posted and visible to parents for 30 days.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Andrea Pittman	TELEPHONE: 661-202-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/24/2023 04:24 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: ULIBARRI FAMILY DAY CARE	FACILITY NUMBER: 360919005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not completing the Mandated Reporter Training before it expired which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2023
	Plan of Correction
1 2 3 4	Licensee will send a copy of the Mandated Reporter Certificate via e-mail no later than 11/7/2023.

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: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Andrea Pittman	TELEPHONE: 661-202-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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