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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192004702
Report Date: 07/19/2023
Date Signed: 07/19/2023 01:45:04 PM

Document Has Been Signed on 07/19/2023 01:45 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PUGH FAMILY CHILD CAREFACILITY NUMBER:
192004702
ADMINISTRATOR:PUGH, SHELONDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 547-6076
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Shelonda PughTIME COMPLETED:
02:30 PM
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On 7/9/2023, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1-Year inspection at the Pugh Family Child Care. Upon arrival, the LPA met with the licensee, Shelonda Pugh, who guided the LPA on a tour of the facility. Family members residing in the home include Two adults (Licensee and her daughter). Per LIS, facility annual fees are current. All adults living in the home have been background cleared. Per the licensee, the hours of operation are Monday through Friday, 6:00 a.m. to 11:00 p.m. (will vary based on parent schedule). During this inspection, there were 2 daycare children (school age children) present. Incidental Medical Services (IMS) were discussed.
The Home is set up as follows:
This is a two-story home with 4 bedrooms, 3 bathrooms, a kitchen, a living room, a formal dining room, a laundry room, a family room, and a garage. There is no pool, spa, or other bodies of water on the premises. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The home has central heating and air conditioning. All windows have screens and are free of cracks, bugs, and debris.
Main Area: Main care is provided in the family, living (front entrance), and formal dining rooms. Children use the bathroom located next to the family room. Children have access to the backyard.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/19/2023
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Living Room / Family Room/Formal Dining Room: In the areas, LPA observed a fireplace that was properly screened via a mirror glass barrier which made it inaccessible to children. LPA observed age-appropriate toys and furniture for the children.
Children’s Bathroom (#1): Children use the bathroom next to the family room. The Bathroom was toured and inspected sink/toilet is in operable condition. The toilet and faucets are clean, safe, and operable. No poison and medications are in the sink cabinet and drawers. The bathroom was observed to be free and clear of hazardous items. The bathroom was clean, sanitized, and in good repair.
Backyard: The backyard was inspected; The backyard has a fence all around. On the right side of the backyard, In the backyard, there is a storage shed with a lock. The outdoor play area was observed to be free of hazards and loose and sharp parts.
Off-limit areas include the home's entire upstairs (3 bedrooms, 2 bathrooms), laundry area (downstairs bedroom in laundry area), and the garage. The stairs have a gate.
Others:
AC/Heating Unit was observed. The AC/Heating Unit is located on the right side of the home and is inaccessible to children via barrels blocking access to the unit.
Bodies of water: Per the licensee, there are no bodies of water in the home.
Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
Fire extinguisher (2A10BC): LPA observed there is a required fire extinguisher (2A10BC) fully charged and located in the kitchen inaccessible to children. It meets standards established by the State Fire Marshall.
Fireplace: The fireplace was observed in the Family room and is screened to make it inaccessible to the children.
Hanging window blind cords: The cords are inaccessible to children.
Licensee will not be providing IMS to the children.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/19/2023
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Isolation area (Illness): Per the licensee, if the child shows signs of illness, he/she will be separated from other children and stay in Family Room.
Medications and cleaning solutions: Detergents/cleaning compounds are in the off limited bedroom. Medications are in the off limited bedroom.
Napping: Children will nap in the designated nap areas with adult supervision. Pre licensee, she only has school-age children, so they do not take naps.
Overnight Care: Pre-licensee does not provide overnight care.
Pets: No pet
Phone service: There is a working cell phone.
Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
Stairs: There is a safety gate or barricaded to make the stairs inaccessible to the children.
The First Aid kit is located in the kitchen, inaccessible to children. The First Aid Kit was observed complete with supplies, LPA observed a first aid manual.
Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license, valid vehicle insurance, and vehicle registration.
Weapons or Firearms: Per Licensee, there are no Firearms at the facility at this time. LPA does not observe any firearms.
Documentation:
· Child files: LPA observed that 2 children's files contained all required licensing documents.
· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with an expiration date (of 10/2024).
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/19/2023
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· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and performed on 06/5/2023.
· Immunization: The licensee and her assistant have the required immunizations (MMR and DTaP). The licensee provided the influenza vaccination.
· Infant Sleeping Plan (LIC 9227) and Sleeping Log: LPA shared the information with the licensee. Per the licensee, NO infant (0-12 months) is enrolled in the facility.
· The licensee posted all required information.
· Mandated Reporter Training: The licensee has completed and renewed the online mandated reporter training at www.mandatedreporterca.com on 7/6/2025
· Staff Personnel File: LPA observed 1 staff information. The file contained all required licensing documents.
The following information was discussed with the licensee:
ü Mandatory Forms for the children's files and provider's files.
ü The licensee is reminded that 100% supervision is required for children at all times.
ü Capacity requirements, Roster requirements, and Documentation requirements for disaster drills (fire and earthquake).
ü Licensee was made aware that it is their responsibility to know the regulations and anyone who assists in providing care. Licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility's phone number; if the phone number is changed, licensing must be notified.
ü Licensee was advised of the requirement to report unusual incidents and injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/19/2023
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ü The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
ü Criminal Record Statement: The licensee [or facility representative] 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 support or exemption prior to the 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.
ü Safe Sleep: LPA discussed the safe sleep regulations with the licensee [or facility representative] 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 the licensee [facility representative] 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.
ü A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety code sections 1596.848(b) and (c). State law prohibits baby walkers, bouncy seats, exersaucer, and other items that fall into that category.
ü Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
ü Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 07/19/2023
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ü 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).
ü Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations.
n Our Quarterly updates come out every 3 months. They are also now in Spanish. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
ü The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 a.m. - 5:00 p.m.
ü A copy of the Safe Sleep Proposed Regulations was provided to the licensee.

No deficiency was cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.

An exit Interview was conducted, and a copy of this Report and a Notice of Site visit were provided to the licensee, Shelonda Pugh.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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