<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364813457
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:30:25 PM


Document Has Been Signed on 05/21/2024 03:30 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:PSD-CRESTLINE HEAD STARTFACILITY NUMBER:
364813457
ADMINISTRATOR:DENISE GRECIANFACILITY TYPE:
850
ADDRESS:22836 FIR LANETELEPHONE:
(909) 338-1470
CITY:CRESTLINESTATE: CAZIP CODE:
92325
CAPACITY:30CENSUS: 12DATE:
05/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Facility Representative, Kenia Flores MartinezTIME COMPLETED:
12:45 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 May 21, 2024 at 09:25a.m., Licensing Program Analyst (LPA) Zirbes, met with facility representative Kenia Flores Martinez 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 on to the Department on May 16, 2024. The unusual incident report was regarding a potential personal rights incident involving child 1 (C1) and staff 1 (S1). Upon arrival, there were 12 preschool children in care with two teachers, and four additional administrative staff.

During this inspection, interviews were conducted with staff and children. In addition, LPA conducted a review of the facility records, staff and child files. Furthermore, LPA completed a safety inspection of the Center at 09:30 a.m.

Based on facility records and confidential interviews, the Department determined that on May 16, 2024 while transitioning from lunch to nap time, there was an incident involving S1 and C1. Interviewees reported that during the incident S1 either grabbed or hooked arms with C1. Interviewees further reported that S1 yelled at C1 during the incident. Due to the incident, C1 started crying and felt scared. Per interviews, S1s conduct was not the result of C1 being an immediate danger to self or others. Interviewees reported, C1 did not sustain injuries as a result of the interaction.

Based on confidential interviews and facility documentation, a type B deficiency is being cited in accordance with California Code of Regulations, Title 22, see LIC 809D.

A notice of site visit was given to facility representative and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the facility representative Kenia Flores Martinez


SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/21/2024 03:30 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: PSD-CRESTLINE HEAD START
FACILITY NUMBER: 364813457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
101223(a)(1)

1
2
3
4
5
6
7
101223 Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Per facility representative, by the close of business on 5/22/24, the Center will submit a plan of correction to the Department.
8
9
10
11
12
13
14
Based on interviews and record review, the Licensee did not ensure C1 was accorded dignity with staff, when S1 grabbed or hooked arms with C1, which resulted in C1 crying and feeling scared. This poses a potential Health, Safety or Personal Rights risk to the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2