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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192004702
Report Date: 05/14/2026
Date Signed: 05/14/2026 02:34:26 PM

Document Has Been Signed on 05/14/2026 02:34 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:PUGH FAMILY CHILD CAREFACILITY NUMBER:
192004702
ADMINISTRATOR/
DIRECTOR:		PUGH, SHELONDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 547-6076
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/14/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:Shelonda PughTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On May 14, 2026, at 1:00 PM., Licensing Program Analyst (LPA) Calloway made an unannounced inspection to the above facility. LPA met with Shelonda Pugh, Licensee, who granted access. LPA and Licensee toured the home inside and outside for an Annual Random inspection. The home is licensed for twelve to fourteen children. At 1:17 PM, LPA observed no day care children in active care with licensee during inspection. Daycare hours are 23 hours. Monday through Friday. All adults working, residing, or volunteering in the facility have Criminal Record Clearance (DOJ/FBI) and Child Abuse Central Index Clearance and are associated with the facility license. Licensee stated that overnight care is provided. LPA reviewed overnight care regulations with the licensee and discussed their plan for providing overnight care. LPA also printed and provided a copy of Title 22, Division 12, Chapter 3, Article 6 – Section 102426 (Overnight Care) to the licensee.
Physical Plant: This is a two story four-bedroom, two-bathroom home with kitchen, dining room, family room, living room, and garage. Childcare is provided: in the downstairs area: living room, family room next to the kitchen, and dining room. The children’s restroom is in the hallway on the left it was clean, with soap, toilet paper, and functioning sink and toilet. The cabinets were locked and there were no shampoos, cleaning chemicals, or razors accessible as hazards. The unused outlets in the home were covered and there are louver shades at the windows. LPA observed furniture that was appropriately aged and at the right height. There was no napping equipment observed. The home was inspected inside and outside for safety, comfort, cleanliness, telephone service, heating and ventilation,
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 05/14/2026
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inaccessibility to poisons, hazardous conditions. The cleaning supplies are kept inside the kitchen in a cabinet up high above the pantry and the medicines are kept upstairs off limits. The windows are screened, free of bugs, cracks, and debris. The fireplace is inside the family room it was observed screened with a glass covering and the home has central air conditioning and heat. The required postings were present on a visible parent wall and the Licensee stated there is no landline phone, but there is an operable cell phone. The stairs were not gated and the temperature inside the home was comfortable. The fire extinguisher (3A:40BC) was full, and the needle was inside the green area. The smoke and carbon monoxide detectors were tested as operable. LPA did not observe an audible device, but there is a single action door handle. Inside the Kitchen, the sharp knives and other sharp utensils were up high above the stove in a cabinet. Licensee stated meals and snacks are provided and there are no known allergies and the refrigerator and freezer were both operable. The off limit inaccessible areas include: the garage, all bedrooms and other bathrooms in the home, and outside area of the yard on the right side.

Outside: The backyard is completely fenced and locked. The fencing material was concrete block and wood and in good condition. There was plastic play equipment and play houses. There is a shaded rest area with tables and chairs. The Licensee stated there are no pets in the home, LPA did not observe any. Licensee stated there are no bodies of water on the premises; LPA did not observe any. The air conditioning (AC) unit in the yard was observed uncovered in an off limits area. Licensee stated the neighboring homes do not have bodies of water.


Other Review: Fire and earthquake drills were current. The fire drill was conducted: 5/9/2026 and the earthquake drill was conducted: 3/15/2026. The child and parent roster is current and complete with all of the required information. Licensee stated there are no weapons or firearms on the premises, LPA did not observe any. The mandated reporter training was reviewed. The Pediatric CPR/First Aid (Exp: 3/22/2027), and the immunization records were available and viewed. LPA viewed the staff and children’s files, the Licensee stated transportation is provided, and there is a first aid kit inside the home. Incidental Medical Services (IMS) policy and Safe Sleep regulations were discussed. LPA discussed the LIC 126 form with the Licensee.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 05/14/2026
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The following was discussed with the Licensee:
Maintain capacity and transparency per posted parent rights, Roster requirements: keep updated information always and maintain roster for three years, Documentation for disaster drills: fire and earthquake drill are conducted every six months. Maintain mandatory forms, signed, for the children’s/staff files, know the updated Safe Sleep regulations, and know your role and responsibilities of being a mandated reporter (LIC 9108 form). Supervision is required for the children in care. If food is brought in, it is properly labeled and check food expiration periodically and milk is served as 1% or nonfat. Licensee is responsible for knowing the regulations as well as anyone who assists in providing care. Temporary absences shall not exceed 20 percent of the hours that the facility provides care per day. If day care is inactive for an extended period, you may notify Licensing. Inaccessibility of hazards must be constantly reassessed depending on the children in care. If the phone number is changed, or someone moves in or out of the home, licensing must be notified. Rooms inside the facility that were noted as off limits cannot be changed prior to notifying licensing.

Regulations prohibit the smoking of tobacco in a private residence that is licensed as a family childcare home and areas of the day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy rocker seats, exer saucers, bassinettes, and any other items that fall into that category. Safe Sleep regulations: require infants sleeping on their back unless specified with LIC 9227 form, no blankets, toys, or pacifiers attached to their clothing and the Licensee will visually observe infants every fifteen (15) minutes and maintain a napping log.
The Licensee was reminded that all adults 18 years old and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a Criminal Record Clearance or Exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
Type A deficiency: Type A deficiency shall be posted for 30 consecutive days along with the Notice of Site Visit (LIC 9213 form) and posted during hours of operation, as there is an immediate risk to the health, safety, or personal rights of children in care.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 05/14/2026
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Licensee shall provide a copy of any Type A deficiency 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 the Type A report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) this form must be placed in each of the children’s files for verification of the Type A deficiency. Failure to do so will result in a civil penalty being assessed.
=Licensee is advised to visit: www.shotsforschool.org for Immunization information.
=Licensee was informed of their responsibility to report suspected Child Abuse (LIC 9108), 1-800-827-8724/760-243-6640. Licensee was informed of the MyChildCarePlan.org website, a
consumer education website that helps families obtain childcare by connecting them to child
care providers and Resource and Referral Agencies (R&Rs) throughout California.
=Family Child Care Providers (Disaster Planning information):
https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
=Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
=Child Care Videos: https://ccld.childcarevideos.org
=Licensee advised to visit the CCLD website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
=Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department prior to providing the IMS. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.
=LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: PUGH FAMILY CHILD CARE
FACILITY NUMBER: 192004702
VISIT DATE: 05/14/2026
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 as an additional resource. LPA 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.
=To improve the quality and value of the new inspection process, a survey may be sent to the
email address provided. Please complete the survey and share your inspection experience. If
you have any questions regarding the process or CARE tools, please send email inquiries to
inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its
tools and methods, please visit the Program website at: www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
=Lead Poisoning: For more information, view PUB 515 and go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600.

Reminder: The CCLD On Duty Worker is available: Monday through Friday from 8:00 AM - 5:00 PM, at (661) 202-3318 for questions, information, and Unusual Incident Reporting (UIR). Once the incident is reported within twenty-four (24) hours via telephone, follow up with a written report (LIC 624B form) via email to: unusualincidentreport@dss.ca.gov. or via fax to: (661) 202-3810 within seven days of reporting.

There are no deficiencies cited during this inspection.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit were given to Shelonda Pugh, Licensee during the inspection. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting may result in $100 civil penalty.
NAME OF LICENSING PROGRAM MANAGER: Francisco Pedroza
NAME OF LICENSING PROGRAM ANALYST: Kuliema Calloway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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