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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364813612
Report Date: 04/19/2023
Date Signed: 04/19/2023 12:32:45 PM


Document Has Been Signed on 04/19/2023 12:32 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:ACOSTA FAMILY CHILD CAREFACILITY NUMBER:
364813612
ADMINISTRATOR:ACOSTA, SHANNON & GILBERTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 228-3365
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:14CENSUS: 6DATE:
04/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Licensee, Shannon Acosta TIME COMPLETED:
12:40 PM
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On April 19, 2023 at 08:10 a.m., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced Annual Required Inspection and met with Licensees Shannon and Gilbert Acosta. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensees. Six (6) children, and two (2) staff members were present at the facility during the inspection. This is a one story, four bedroom, two bathroom home with kitchen/dining, living area, toy room and detached garage. The on limits areas are the toy room, dining room, living room, kitchen, bathroom (located in hallway), and backyard. The off limit areas consisted of all bedroom, the primary bathroom, detached garage and a portion of the backyard. The off limits areas were inaccessible via child safety gates and locked doors. There are no pool/spa or body of water on the premises. Family members residing in the home include licensees, and two children ages (10 , 15). Current days and hours of operation are Monday thru Friday, 06:00a.m. to 6:00 p.m..
Physical Plant:
The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines, and hazardous items, that can pose a danger to children. LPA observed medications, and cleaning products in the key locked hallway closet. Cleaning products were also observed in an inaccessible high kitchen cabinet. LPA observed a 2A10BC fire extinguisher in the kitchen. The fire extinguisher was serviced in 2023. Safe and age appropriate toys, play equipment and materials were observed. The smoke detector and carbon monoxide detector, were tested and in working order. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed in the on limit area. The living room is the designated area for ill children in the child care.

LPA observed age appropriate napping equipment, (blankets, bare environment play yard).
Report continued on page two
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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 4


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: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 364813612
VISIT DATE: 04/19/2023
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Report continued from page one

Per Licensee, there are weapons or firearms stored on the premise. Based on LPAs observation, the weapons/firearms were stored according to the regulations. The home has a fireplace and a wood burning stove, which was surrounded by a barrier.

Bathroom: Shower/tub free of hazards. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Toilet and faucet are clean and operable.

Outdoor: The backyard is completely fenced. One section of the outdoor area is off limits and is used by the family animals and household storage. LPA observed a large wooden climbing structure which was secured to the ground and place on sand/dirt. LPA observed an octagon climber and advised the Licensee to ensure the fall zone required by the manufactures are being met.

Per conversation with the Licensees there are two dogs and three cats in the home. Per Licensee the cats interact with the children. The dogs do not interact with the children. Per License, dogs and cats are current on shots and licensing.

CPR/First Aid expires 2/18/25 and mandated reporter training was current.



LPA reviewed ten child files, and the Licensees files. Based on LPAs record review all files were complete and contained all required information, to include the 15 minute checks and safe sleep plan.

The following were observed: Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Emergency and Disaster Information (LIC610A).

The following was discussed with the licensee:

Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.


Report continued on page three

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 364813612
VISIT DATE: 04/19/2023
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 Report continued from page two

Licensee reminded that 100% supervision is required at all times to children in care. Licensee was made aware that it is he/her responsibility to know the regulations as well as anyone who assists in providing care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified

The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.



Report continued on page three
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 364813612
VISIT DATE: 04/19/2023
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Report continued from page three


Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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

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 inspectionprocess@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/process

Based on LPAs record review there were zero citations issued today.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Shannon Acosta.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4