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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808389
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:54:24 PM


Document Has Been Signed on 12/21/2023 02:54 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:CHAMPIONS/EAGLE RANCHFACILITY NUMBER:
364808389
ADMINISTRATOR:CYNTHIA CUMMINGSFACILITY TYPE:
840
ADDRESS:12545 EAGLE RANCH PARKWAYTELEPHONE:
(760) 948-6820
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:56CENSUS: 5DATE:
12/21/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Nicole Ahumada, TeacherTIME COMPLETED:
03:00 PM
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On December 21, 2023, Licensing Program Analyst (LPAs) Calloway and Ali made an unannounced inspection for the purpose of conducting a Required Annual inspection. LPAs met with the teacher who granted access. LPAs toured he facility with the teacher and observed 5 children in active play and 2 staff. The school age program consists of 2 classrooms. The facility operates from 6:00 am to 6:30 pm Monday-Friday. Center Director was unavailable during inspection.
Physical Plant: LPAs observed two classrooms, telephone service, heating, lighting, and ventilation are adequate. One classroom was not in use. There are cubbies for children's belongings (labeled) in each classroom. Furniture, equipment, toys, and materials were age appropriate. Drinking water is available inside the classrooms in the form of water dispensers and disposable cups. No napping equipment. Medication is stored in the kitchen up high. First Aid Kits was observed in kitchen, extra bandages are kept inside the classroom. Fire alarm pull, fire extinguisher, smoke detector and carbon monoxide detector (operable).
Bathrooms: LPA inspected the children's bathroom. There is one (1) toilet and one (1) sink, functioning properly and age appropriate (no hazards). LPA observed soap, toilet paper, and paper towels readily available. Staff restrooms (labeled) is located next to child bathroom there was a storage cabinet inside (unlocked) with cleaning supplies accessible to the children.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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: CHAMPIONS/EAGLE RANCH
FACILITY NUMBER: 364808389
VISIT DATE: 12/21/2023
NARRATIVE
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Kitchen: There is fully equipped kitchen with refrigerator/freezer, toaster, stove, and sink. The facility provides morning and afternoon snacks. Menus are posted. LPA observed allergy list posted inside the kitchen. LPA observed an appropriate amount of food and snacks. The chemicals are kept separate from the food. Cleaning supplies are kept in a custodial closet inside the staff bathroom. LPA recommended a labeling system for the stored and frozen food to assist with expiration date on food storage.
Outside: Outdoor play equipment was inspected for health, safety, cushioning materialrepair and age appropriateness. Children play on the elementary school's playground. LPAs observed a large, securely anchored play structure with padded ground for cushioning basketball hoops and swings (sand underneath). There is shade and benches for rest and water fountains. The area was free of debris. There are no bodies of water on the premises.
Other: Children and staff files were reviewed. Current Pediatric CPR and First Aid (expires 10/29/24). Transportation is provided (insurance verified) and medical policy reviewed. Disaster Drills: Fire/Earthquake current (12/7/2023) and Roster (not current). Children are inspected for illnesses as they arrive. There is a separate area for isolation and care of ill children behind the supervisor’s desk on a cot. The cot is sanitized after each use. Teacher/child ratios were observed as well as sign in/out sheets. Staff was reminded to access the Licensing website at ccld.ca.gov to obtain information about the most recent regulatory changes and the Quarterly Updates. Medications are stored in kitchen. A review of medication policy indicated that prescription medication is administered only with parent's written permission. The management staff administers medication and documents the dosage, date, and time onto a log. Medication is brought and taken home by the parent daily or stored in the backpack. Medication is properly labeled and stored in its original container.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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: CHAMPIONS/EAGLE RANCH
FACILITY NUMBER: 364808389
VISIT DATE: 12/21/2023
NARRATIVE
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This facility does not provide Incidental Medical Services – IMS. LPA did not observe medication and equipment/supplies. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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: http://www.ada.gov/childqanda.htm.

The On Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM for questions, information, and Unusual Incident Reporting.

Lead Poisoning: For more information, go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600.

Additional forms and a copy of Title 22 Regulations may be obtained at the department's website: www.ccld.ca.gov. Center informed Child Care Advocates: You can now sign up for Quarterly Updates and PINs for one or more programs through our DSS website at www.ccld.ca.gov. Click on “Receive Important Updates” located in the right middle part of the page, immediately above the Quick links. Put your email address and choose which program(s) you would like to subscribe to and click “subscribe” to review updates/regulations on the department website.

Per Title 22 Regulations, there are deficiencies cited during this inspection. See 809D pages.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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: CHAMPIONS/EAGLE RANCH
FACILITY NUMBER: 364808389
VISIT DATE: 12/21/2023
NARRATIVE
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Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

Exit interview was conducted and a copy of this report was read, a Notice of Site Visit, and Appeal Rights were provided to Nicole Ahumada, Teacher at the facility. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain posting will result in a $100 civil penalty.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/21/2023 02:54 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: CHAMPIONS/EAGLE RANCH
FACILITY NUMBER: 364808389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)(1)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. (1) Storage areas for poisons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in poisons were not locked in the storage cabinet upon inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Director will submit proof of correction to Licensing by POC date of 12/22/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 12/21/2023 02:54 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: CHAMPIONS/EAGLE RANCH
FACILITY NUMBER: 364808389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, record review, the licensee did not comply with the section cited above in having the water/lead teast available during inspections which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Director will provide water test by chosen POC date listed above
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, record review the licensee did not comply with the section cited above in S3 did not have LIC 503 in staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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S3 will provide to Licensing by POC date above
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) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 12/21/2023 02:54 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: CHAMPIONS/EAGLE RANCH
FACILITY NUMBER: 364808389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101515(b)
School-Age Child Care Center Director Qualifications and Duties
(b) All school-age child care centers shall have a director.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review the licensee did not comply with the section cited above in providing the information for new center director to Licensing within 10 days of the change which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Director will provide proof to Licensing by chosen POC date above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7