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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 364842907
Report Date: 05/30/2023
Date Signed: 05/30/2023 01:35:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2023 and conducted by Evaluator Kuliema Calloway
COMPLAINT CONTROL NUMBER: 12-CC-20230426143711
FACILITY NAME:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
364842907
ADMINISTRATOR:PEREZ, PETRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(442) 285-7175
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY:14CENSUS: 3DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Petra Perez, LicenseeTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Allegation: Licensee did not properly supervise daycare child.
INVESTIGATION FINDINGS:
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On May 30, 2023, Licensing Program Analyst (LPA) Kuliema Calloway made an unannounced complaint inspection to the Perez Family Child Care. The purpose of the inspection was to deliver findings for the above allegation. LPA met with Licensee who granted access.

Based on observation and interviews, the evidence determined that while in care, Child 1 fell in a play area that was not age-appropriate thus, causing the child to sustain a facial injury which results in Neglect/ Lack of Supervision. This is a Type A deficiency where a day care child suffered an injury while in care that needed immediate medical attention.

Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 12-CC-20230426143711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 364842907
VISIT DATE: 05/30/2023
NARRATIVE
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LPA Calloway informed the Licensee to provide a copy of this licensing report dated 5/30/2023 with the Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview was conducted and a copy of this report, Notice of Site Visit, and Appeals Rights were discussed and provided to the licensee. A Notice of Site visit was posted and must remain posted for 30 days. Removal of posting is subject to a $100 civil penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 12-CC-20230426143711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 364842907
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2023
Section Cited
CCR
102352(f)(1)
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102352(f)(1)Family Day Care" or "Family Child Care" means regularly provided care, protection and supervision of children, in the care giver's own home, for periods of less than 24 hours per day, while the parents...away... This requirement was not met as evidenced by:
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Licensee will provide a written declaration that all staff will provide 100 % supervision to the day care children while in care. Provide the written proof to the Department by POC date of 5/31/2023.
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Based on observation, record review, and interview a day care child sustained an injury while in care of the day care home. The injury required medical attention. Which posed an immediate health, safety, or personal rights risk for the persons in care.
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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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3