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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191225670
Report Date: 09/22/2023
Date Signed: 09/25/2023 04:00:24 PM

Document Has Been Signed on 09/25/2023 04:00 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:YMCA OF METRO LA/SANTA CLARITA VALLEY VIEWFACILITY NUMBER:
191225670
ADMINISTRATOR:REBECCA KELLYFACILITY TYPE:
850
ADDRESS:19414 W. SIERRA ESTATES DRIVETELEPHONE:
(323) 974-0258
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Robyn Kamp, DirectorTIME COMPLETED:
01:00 PM
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On September 22, 2023 Licensing Program Analyst (LPA) Isabel Ortega met with facility Director Robyn Kamp 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 to the Department on September 14, 2023. Upon arrival, there was no children in care and 2 staff. The unusual incident report is regarding an accident during the hours of care resulting in injuries.

Description of incident: On 9/11/2023 at approximately 4:00 p.m. Child#1, tripped on his own feet while attempting to kick the ball and fell on face.

During this inspection LPA observed the facility roster and incident injury report provided to parent. In addition, LPA completed a safety inspection observation of the facility. LPA toured a total of two classroom bungalows Number 502 and 503 and outdoor playground.

All students were visually supervised, staff confirmed child#1 fell and hurt his top lip and was slightly bleeding. Staff #1 provided first aid to child. Child#1's behavior was normal, and did not express any major pain besides a sore lip and scape on knee. On 9/13/2023 facility was notified child was taken to the dentist and according to parent a follow up is needed for further determination on tooth. Child was back at school the following day 9/12/2023 and had no complaints.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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: YMCA OF METRO LA/SANTA CLARITA VALLEY VIEW
FACILITY NUMBER: 191225670
VISIT DATE: 09/22/2023
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Facility followed protocol, three staff were providing care and supervision during the incident. According to interviews conducted Child #1 was playing kick ball at the court and lost balance when attempting to kick the ball causing child#1 to fall and get injured. Parent was notified in a timely manner and UIR was reported to the Palmdale Regional Office within the time frame required. Child #1 has resumed normal activities.

No deficiencies will be cited today. A notice of site visit was provided and requested to be posted for 30 days. An exit interview was conducted, a copy of this report, notice of site visit and appeal rights were provided to facility.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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