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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405109
Report Date: 06/25/2024
Date Signed: 06/25/2024 01:12:09 PM

Document Has Been Signed on 06/25/2024 01:12 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:CONGREGATION BETH SHALOMFACILITY NUMBER:
197405109
ADMINISTRATOR/
DIRECTOR:		CAROL BLOOMFACILITY TYPE:
850
ADDRESS:21430 CENTRE POINTE PARKWAYTELEPHONE:
(661) 254-2411
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 96TOTAL ENROLLED CHILDREN: 96CENSUS: 0DATE:
06/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Carol Bloom, DirectorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On Tuesday, June 25, 2024, Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with director Carol Bloom who granted access and guided LPA Rivera on a tour of the facility.

This is a preschool program that serves children ages 2 to 6 years. This program operates Monday to Friday 6:30 a.m. – 6:30 p.m. Sign in and out takes place in the classrooms. Teacher and child ratio not observed due summer break and no children or staff present. Annual Fee is current, and all staff are fingerprinted cleared.



At approximately 9:39 am, LPA entered classrooms #3 and #4 (two-year-old) split. LPA Rivera observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside the top cabinet with a padlock making it inaccessible for children to reach. LPA Rivera observed a step trash bin with a lid. LPA observed cubbies for children to store their personal belongings.

At approximately 9:45 am, LPA entered classrooms #7 and #8 (three-year-old) split. LPA Rivera observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside the top cabinet with a padlock making it inaccessible for children to reach. LPA Rivera observed a step trash bin with a lid. LPA observed cubbies for children to store their personal belongings.

At approximately 9:51 am, LPA entered classrooms #9 and #10 (pre k) split. LPA Rivera observed age-appropriate furniture and equipment to be in good condition, free of sharp, not loose, or pointed parts and age-appropriate toys accessible to children. LPA observed cleaning solutions stored inside the top cabinet with a padlock making it inaccessible for children to reach. LPA Rivera observed a step trash bin with a lid. LPA observed cubbies for children to store their personal belongings.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 06/25/2024
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Classrooms #5 and #6 is currently not being utilized due to low enrollment. Director would like to convert the classrooms into an infant program. The classrooms are currently being utilized as a storage.

LPA Rivera observed restrooms located in the hallway by director’s office. LPA observed a total of 8 toilets, 7 hand washing sinks, and two urinals. LPA observed the restroom to be in good condition and free from hazards.



Heating, lighting and ventilation were evaluated by LPA Rivera. LPA observed central AC /heater and vents located on the ceiling. LPA observed the thermostat located in classroom 9 and the temperature to be at 80. LPA observed the fire extinguishers located in classrooms and hallways and the valve on the required 2A10BC fire extinguishers indicating fully charged and serviced on 7/6/2023. Smoke detectors were not tested during this visit due to the detectors being wired to the emergency pull down fire alarm system. LPA observe a carbon monoxide detector in classroom # 3. LPA Rivera tested and heard the sound and is operable. The last emergency drill was conducted on 5/17/2024.

LPA observed sleeping cots to be in good condition. First aid kits supplies are kept inside the classrooms and LPA observed the kits to be complete with band aids, gauzes, adhesive bandages, and antiseptic wipes. During this visit, director Carol stated had a child with severe food allergies. LPA reminded if the child returns to ensure the medication is not expired. LPA informed best practice is to have the medication in the child’s classroom in a top cabinet and make it inaccessible for children. LPA Rivera asked if there were any poisons, firearms, weapons, or bodies of water. The director stated there were no firearms, weapons, no poisons nor bodies of water. LPA did not observe firearms or weapons, poisons, nor bodies of water. Director stated the ill isolation area takes place in the director’s office and children utilize the girls handicap stall. Lead testing was conducted on 12/30/2022 and there was lead exceedance. February 2023, the faucets were replaced but not being used.

At approximately 10:30 am. LPA Rivera entered the outdoor play area (garden area, play yard, and grass yard). LPA Rivera observed the playground to be fenced all around and the gates closed with keypad locks. LPA Rivera observed the equipment to be in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA Rivera observed play structure equipment to be age appropriate and areas around or under high climbing

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
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: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 06/25/2024
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equipment, are cushioned with woodchips that may absorb a fall. For adequate shade, LPA Rivera observed 3 hip roof shade structures. LPA observed step trash bin with a lid. LPA observed total of 3 sheds, one in the garden area and two in the play yard. LPA observed the sheds closed and locked with a padlock. For outdoor water drinking, staff bring out water pitchers and children sippy cups.

This program provides am and pm snacks. Meals are brought from children’s home. LPA Rivera informed director Carol that any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. For water drinking, LPA Rivera observed water pitchers, disposable cups and sippy cups in the classrooms. LPA observed the food preparation area to be clean and free of litter, rubbish, rodents, and/or any other vermin and storage containers for solid waste, including movable bins with tight-fitting covers that are kept on, and in good repair. The facility was observed to be free of flies, other insects and rodents.

The following documents were posted in a prominent, publicly area front lobby: Facility License, Notification of Parents' Rights (PUB 393), Personal Rights (LIC 613A), Menu, and Daily Schedule.

LPA Rivera reviewed the children’s roster, children’s files, staff files and no sign in sheets (summer break).

LPA Rivera observed director Carol Bloom American Heart Association Pediatric First Aid/CPR certification dated 3/24/2023, Preventative Health and Safety dated 7/29/2001 and has proof of immunization against Pertussis, MMR and Influenza. Director has completed the child abuse mandated reporter training dated 6/2/2024. Director was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com


The following was also discussed with director:
1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Breakfast/Lunch/Snack Menus: Menus are required to be posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days must also be available upon request.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
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: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 06/25/2024
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3. Current Children’s Roster: Each childcare facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

4.LIC 125 Entrance Checklist provided, and LPA informed that forms, regulations and quarterly updates can be accessed on the Child Care Licensing website at: www.ccld.ca.gov.

5.Pediatric First Aid and CPR: At least one person trained in Pediatric First Aid and CPR and EMSA approved must be present.

6.Designated Staff: The name of the childcare center director or fully qualified teacher(s) designated to act in the director's absence must be on file.

7.Qualifications: Educational background, training, and/or experience for each staff present must be available for review.

8. Immunization Requirements: Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles or influenza declination

9.Children’s Records: must be available for review; including but not limited to, the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

Director Carol Bloom was reminded that all adults 18 and over, 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 Child Care Center. 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

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
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: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 06/25/2024
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LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Licensee Carol Bloom was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

A notice of site visit was given and must remain posted for 30 days. Failure to maintain posting as required will result in a $100.00 civil penalty. Exit interview conducted and report was reviewed with director Carol Bloom.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Mayra Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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