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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364820249
Report Date: 03/23/2021
Date Signed: 03/23/2021 04:16:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SHIPMAN FAMILY CHILD CAREFACILITY NUMBER:
364820249
ADMINISTRATOR:JACQUELINE SHIPMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 949-8394
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:14CENSUS: 9DATE:
03/23/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jacqueline ShipmanTIME COMPLETED:
03:36 PM
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Licensing Program Analyst (LPA) Thompson-Miller met with Licensee, Jacqueline Shipman, for a Case Management Incident inspection (virtual) involving an Incident Report dated March 12, 2021. The incident occurred on March 12, 2021. Due to COVID-19 this inspection/visit will be conducted via Telephone call. Purpose is to view the video footage.

Description of the incident: Child in care was being unruly and having a temper tantrum
Child #1 was asked to put shoes on. Child then began screaming, hitting the License several times, frightening to other children in care and attempted several time to exit the home. Licensee attempted to calm child down, parent was called, 911 was called (later cancelled). Child and siblings are no longer attending as of the date of the incident. LPA Thompson-Miller watched the video footage of the incident.

Based on information provided and interviews conducted the incident does not appear to have been the result of any violation of the Title 22 regulation, therefore, no deficiencies were cited.
An exit interview was conducted and a copy of this report was read and forwarded to the Licensee, Jacqueline Shipman via email for confirmation with "Read Receipt" on this date along with the Notice of Site Visit/Inspection.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
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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