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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364807446
Report Date: 09/20/2019
Date Signed: 09/20/2019 04:09:27 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:MC ADAM FAMILY CHILD CAREFACILITY NUMBER:
364807446
ADMINISTRATOR:MC ADAM, SEBRENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 240-4499
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:14CENSUS: DATE:
09/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Sebrena McAdamTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Montoya, Phillips and Licensing Program Manager (LPM) Yates made an unannounced visit to the McAdams Family Child Care home. The purpose of the visit was to conduct a case management Incident Inspection in regards to and Unusual Incident (UIR) that was reported to the Palmdale Child care office on 9-13-2019. LPAs and LPM met with Licensee Sebrena McAdams to discuss UIR. LPA interviewed licensee and the following information was revealed.

Per licensee, present during the time of the incident licensee, 3 day care children (ages 1, 2.5 , 8) and one adult daughter. Licensee states, I was standing out at the front door with the incident occurred. The child involved was a 2 years old child, who was in the back yard unsupervised. Child ran through an open back door and entered into the unsecured ball rack which was standing up right. Child fell backward inside the ball rack which injured the back of his head. There were no balls in the rack at the time of the incident. . The licensee reports cleaning the child's head with a damp cloth and a cold pack. Licensee immediately contacted the mom. The mothers arrival to the child care facility child was transported to the medical clinic. Child was not bleeding when mother pick him up. The Mother reports child received 8 staples to the back of his head.

Licensee provided LPA's and LPM copy of the medical report. Child was treated for Laceration of the head, scalp laceration repair.

Based on the information and interview provided. Child was unsupervised during the time of the incident:

Deficiency Sighted See LIC 809D.

Exit interview conducted as copy of this report, notice of site inspection and appeal rights were discussed and left with licensee.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 789-6944
LICENSING EVALUATOR NAME: Steven MontoyaTELEPHONE: (661) 789-8932
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2019
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: MC ADAM FAMILY CHILD CARE
FACILITY NUMBER: 364807446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2019
Section Cited

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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:(2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
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This requirement was not met based on Licensee failed to secure the ball rack. The child sustained a head injury, which posed an immediate health and safety risk to 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: Steven MontoyaTELEPHONE: (661) 789-8932
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2019
LIC809 (FAS) - (06/04)
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