364808392-8-22-2023-12-CC-KZIS-CUY26E-20230822170702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364808392
Report Date: 08/22/2023
Date Signed: 08/22/2023 05:07:16 PM

Document Has Been Signed on 08/22/2023 05:07 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/LIBERTY		FACILITY NUMBER:	364808392
ADMINISTRATOR:	AMBER KINSEY		FACILITY TYPE:	840
ADDRESS:	12900 AMETHYST ROAD		TELEPHONE:	(760) 243-2002
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	56	CENSUS: 25	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Facility Representative Meoka Alvis		TIME COMPLETED:	05:20 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 August 22, 2023 at 12:40 p.m. Licensing Program Analyst (LPA) Zirbes met with the Facility Representative Meoka Alvis. The purpose of the inspection was to conduct an unannounced required one year inspection. LPA disclosed the purpose of the inspection to the Facility Representative. Present during today’s inspection were 25 school age children, and four teachers. The school age program consists of two classrooms. The program operates Monday to Friday. Mornings - 6:00am to 8:30am; Afternoons - Mon. - Friday 12:30pm to 6:30pm. During Summer and school breaks the Center operates 6:00 am - 6:30 p.m. Indoor/Children's Area: Child care center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction. Cleaning compounds are stored in the classroom in a high inaccessible cabinet equipped with a combination child safety lock. The Center was free of flies, other insects, or rodents. Each classroom was equipped with tables and chairs to meet children’s needs. All play equipment and materials used by children are age-appropriate, children have individual cubbies labelled with their names for storage of personal belongings. Trash cans for solid waste have tight fitting lids. All materials and surfaces are toxic free. No fireplaces were present in the center classrooms. Carbon monoxide detectors and smoke detectors are located in the classroom and is a dual alarm connected through the elementary school. A fire extinguisher was located in the Center. The Center had working telephone service on the premises. There is an isolation area for children who become ill while in care. At the time of this inspection, the temperature inside one of the classrooms was 84 degrees. Per facility representative, the air conditioning unit is in the process of being replaced. LPA reminded the Center that in rooms that children occupy the minimum temperature shall be 68 degrees and the maximum temperature shall be 85 degrees. Sign in/out sheets were available and are completed each day. Sign in an out sheets included information for school drop off and pick up. Smoking prohibited on the premises. Staff complete daily inspections for illness. LPA did not observe prohibited child care items at this time. All electrical outlets were inaccessible. Firearms/weapons are not allowed or stored on premises. There are no bodies of water on the premises. The Center has the menu posted. Children have access to water while in the classrooms via cups and bottled water dispenser. Report Continued on page two

SUPERVISOR'S NAME: Lady King	TELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal Zirbes	TELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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/LIBERTY	FACILITY NUMBER: 364808392
	VISIT DATE: 08/22/2023

NARRATIVE

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Restrooms: The Center has two restrooms, one in each classroom. Restrooms were age appropriate and contained toilet paper, paper towel and soap dispensers. LPA observed the toilet paper was placed on top of the toilet paper holders. LPA advised the Center to place the toilet paper in the holder to ensure a sanitary environment. At the time of this inspection the Center had two toilets and two sinks for the children. There was one additional bathroom for staff members. The Center has a third toilet, however the toilet was not being utilized at the time of this inspection. The third toilet area was being utilized as a storage area. At the time of this inspection, the facility has a total of 32 children enrolled, therefore in order to maintain the ratio of one toilet and one handwashing fixture for every 15 children, the third bathroom needs to be cleaned out and utilized. A technical advisory notice was provided to the Center.
Food Service: The Center provides two snacks for the children.

Outdoor: The Center utilizes the playground on Liberty Elementary. The playground is enclosed by a gate. The outdoor play space has climbing structure, grass area, blacktop area and a shaded area. The climbing structure was placed on wood chips and was secured to the ground. Zero bodies of water were observed. Drinking water is readily available to the children when outside via personal water bottles and a water jug and cups brought out with the staff.

During the inspection teacher child ratios were observed, and found to met the requirements. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.

Staff/Child Records
LPA reviewed five child records and four staff member records during this inspection. Child files were complete and contained the required documentation. Based on LPA review, two of four staff files (S3, S4) reviewed were missing verification of a health screening that was completed not more than one year prior of seven days after employment. A type B citation was issued, refer to LIC 809D. Furthermore, based on LPAs record review, one of four files (S3) reviewed was missing documentation of their immunization's (TDAP, MMR, Flu,TB). In addition, one of four staff files (S4) reviewed was missing documentation of the mandated reporter training. Technical advisory notices were issued. A staff member was on site who had current CPR/First Aid.

Report continued on page three

SUPERVISOR'S NAME: Lady King	TELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal Zirbes	TELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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/LIBERTY	FACILITY NUMBER: 364808392
	VISIT DATE: 08/22/2023

NARRATIVE

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Facility Records
LPA and Facility representative reviewed the LIC 311A Records To Be Maintained At The Facility. The facility provided documentation that the required lead testing was completed in October 2022. Per conversation with the facility staff member, the Administrator on file with the Department is no longer working at this site. LPA advised the Center to submit the required documentation to the Department so the Administrator can be updated. A technical advisory notice was issued.

Health Related Services
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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.
At the time of this inspection, the Center has zero prescription or non prescription medications on site.

Postings:
The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393), car seat law (PUB 269), emergency disaster plan.

Topics Discussed:
Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Director shall permit the Department to inspect the center, and to privately interview children or staff, to determine compliance with or to prevent violations of laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

Report continued on page five.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal Zirbes	TELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 9

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/LIBERTY	FACILITY NUMBER: 364808392
	VISIT DATE: 08/22/2023

NARRATIVE

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Facility representative was advised of the requirement to report Unusual Incidents. Facility representative informed to utilize the Unusual Incident Report/Injury Report LIC624 when submitting the report to the department (email address: unusualincidentreport@dss.ca.gov). 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 center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The On-Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to insectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Based on LPA observations and record review one type B citation and four technical advisory notices were issued.
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 Meoka Alvis.

SUPERVISOR'S NAME: Lady King	TELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal Zirbes	TELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2023 05:07 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/LIBERTY	FACILITY NUMBER: 364808392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(g)(1)

Personnel Requirements

(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two of four staff files reviewed were missing verification of a health screening that was completed not more than one year prior of seven days after employment, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	Per facility representative, the staff will obtain the required health screening and the documentation will be added to the files. Facility representative will utilize a checklist to ensure the files contain all required information. Facility representative will review the staff files twice a year to ensure completeness.

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: Lady King	TELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal Zirbes	TELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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