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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364807986
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:42:20 PM

Document Has Been Signed on 02/07/2024 03:42 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:SBCUSD-EMMERTON PRESCHOOLFACILITY NUMBER:
364807986
ADMINISTRATOR:LAURA RAMOSFACILITY TYPE:
850
ADDRESS:1888 ARDEN AVENUETELEPHONE:
(909) 862-6400
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY: 24TOTAL ENROLLED CHILDREN: 21CENSUS: 14DATE:
02/07/2024
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Facility Representative Andrew SanchezTIME COMPLETED:
03:50 PM
NARRATIVE
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On February 7, 2024 at 11:15 a.m., Licensing Program Analyst (LPA) Zirbes met with facility representative Andrew Sanchez to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted to the Department on January 31, 2024. The unusual incident report was regarding an incident that occurred in the outdoor activity space, which involved child 1 (C1) receiving emergency medical services on January 30, 2024. Upon arrival today, there were zero children in care, however 14 preschool age children arrived during the inspection. One teacher and two aides were present and providing supervision at the time of the inspection.

During this inspection, interviews were conducted with two staff members, child files and personnel records were reviewed. In addition at approximately 1:15 p.m., a safety inspection of the indoor and outdoor activity space was conducted by LPA. Based on LPA observation there were zero hazards observed.

Interviews revealed that on January 30, 2024, S1 observed C1 slide down the slide, then observed C1 looking around for a few minutes while sitting at the exit of the slide. S1 then observed C1 slump over and fall from the exit of the slide. S1 responded and observed C1 was unresponsive. S1 then called Program Specialist and then 911. The two phone calls occurred within a minute of each other. Due to C1 being unresponsive, there should have been no delay in getting medical treatment for C1. Therefore, a deficiency is being cited based on interviews, in accordance with California Code of Regulations, Title 22, see LIC 809D.



A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with facility representative Andrew Sanchez.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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Document Has Been Signed on 02/07/2024 03:42 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 02/07/2024 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: SBCUSD-EMMERTON PRESCHOOL
FACILITY NUMBER: 364807986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2024
Section Cited
CCR
101226(c)

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101226(c) Health-Related Services: ...obtain emergency medical treatment without specific instructions from the child's authorized representative... if the nature of the child’s ... injury is such that there should be no delay in getting medical treatment for the child. This requirement is not met as
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Per facility representative, a training will be completed with the staff. A copy of the training sign in sheet and the training topics will be submitted to the Department.
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evidenced by: The Licensee did not ensure there was no delay in C1 receiving medical treatment, when one phone call was made prior to 911 after C1 was observed unresponsive on the playground. This poses a potential risk to the health, safety or personal rights of the persons 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:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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