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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191231624
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:04:01 PM

Document Has Been Signed on 05/10/2023 12:04 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:LOR FAMILY DAY CAREFACILITY NUMBER:
191231624
ADMINISTRATOR:CHURSI LORFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 804-7018
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kanchana Chongjai, Assistant TIME COMPLETED:
12:30 PM
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On May 10, 2023, Licensing Program Analysts (LPA) Annelise Villa, met with licensee's assistant, Kanchana Chongjai, who guided analyst on a tour of the facility for the One Year Required inspection. Upon arrival LPA observed 4 children in care and 1 adults caring for them. Family members residing in the home include Licensee and licensee’s sister, brother in law, licensee’s nephew and niece in law. Facility hours of operation are Monday - Friday 9:00 am to 6:00 pm. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: This is a one story family home. The home consists of a kitchen, living room, three bedrooms, 1 bathroom and a detached garage. The primary care for children will be conducted in the living room. Bathroom #1 located on the back left side of the living room. Children have access to both bathrooms. The living room has a fireplace that is inaccessible to children and securely barricaded. The home was inspected inside and out for safety, comfort, cleanliness, orderliness, telephone service (land line), heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds and medicines are kept in the kitchen which is inaccessible and off limits to children in care, under the kitchen sink with an operable safety latch, sharp knives are kept in the kitchen on a high counter and are inaccessible to children. Children nap on mats or cribs in the daycare area.

Safe and age appropriate toys, play equipment and materials were observed. The smoke detector, carbon monoxide detector and Fire Extinguisher (2A10BC) are all in operable condition. Electrical outlets are inaccessible. No recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the living room. Per Licensee, there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).

Bathroom: LPAs observed toilet and faucet are clean and operable. There are no shampoos or cleaning products in bathroom #1.

Continued on LIC 809-C

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: LOR FAMILY DAY CARE
FACILITY NUMBER: 191231624
VISIT DATE: 05/10/2023
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Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. The home has a clean and fully stocked refrigerator/freezer. Lunch and snacks are provided. Licensee stated she currently is not a participant in a food program.

Outdoor: The back yard is off limits. The back yard is made inaccessible by a dual safety latch on the glass sliding door The front yard is completely fenced in. There are no pets on the premises. LPAs observed age-appropriate toys, well secured and safe for children.

Pools/Spas/Bodies of Water: There are no bodies of water in the premises.

Advisory/Other: First Aid kit was observed in the kitchen with supplies readily available. CPR/First Aid expired 2/2022. Mandated Reporter expired on 2/2022. LPA reminded licensee mandated reporter training and CPR must be completed every 2 years. Licensee will retake Mandated Reporter Training and send certificate of completion to LPA no later than May 11, 2023. Licensee will enroll in CPR training and send proof of completion no later than June 15, 2023. Last fire/disaster drill was completed on May 3, 2023.

The facility annual fees are current. Licensee had all the required posted documents: Facility License (LIC 203), Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148). Children files were found to be complete. Fire/Disaster drills are maintained current. Fire disaster was completed on 2/1/2023.

Documents Provided and or Discussed: Fire Drill Log, Postings, Employee's and Children's records, Safe Sleep PIN 20-24-CCP and Individual Sleeping Plan (LIC9227). Licensee currently does not have child care insurance.

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.

Continued on LIC 809-C

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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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: LOR FAMILY DAY CARE
FACILITY NUMBER: 191231624
VISIT DATE: 05/10/2023
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LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs 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.

An exit interview was conducted, a copy of this report was reviewed and provided to licensee along with the appeal rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 12:04 PM - It Cannot Be Edited


Created By: Annelise Villa On 05/10/2023 at 11:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: LOR FAMILY DAY CARE
FACILITY NUMBER: 191231624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above with no persons having CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee will complete CPR training at the earliest possible date, and before June 15, 2023. Licensee shall also send proof of completion to LPA Villa by the above date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Mariela Ramon
LICENSING EVALUATOR NAME:Annelise Villa
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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