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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405109
Report Date: 07/28/2026
Date Signed: 07/28/2026 01:15:47 PM

Document Has Been Signed on 07/28/2026 01:15 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:
07/28/2026
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:33 AM
MET WITH:President Brenda Rubin and
Director Carol Bloom.		TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On Tuesday, July 28, 2026, Regional Manager (RM) George Mingle, Licensing Program Manager (LPM) Lady King-Lewis, and Licensing Program Analyst (LPA) Mayra Rivera held a Conference with President Brenda Rubin and Director Carol Bloom.

The purpose of the conference is to discuss about the incident that occurred on Thursday, June 11, 2026, involving a child finding a rattle snake in the playground house and that the Department takes children's safety very seriously and stressed the importance of ensuring that the children's personal rights are protected, at all times. Also, the following regulations were discussed, and licensee was provided with copies of the Title 22 Regulations pertaining to:

Personal Rights 101223 (a)(2), (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs.

Accountability 101214 (a)(1), (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed child care center and for the establishment of policies concerning its operation. (1) If the licensee is a corporation, the governing body shall be active and functioning in order to ensure such accountability.

Responsibility for Care and Supervision 101229 (a)(1), no child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

Lady King
Mayra Rivera
DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2026
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: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 07/28/2026
NARRATIVE
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Buildings and Grounds 101238 (a)(1), (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees, and visitors. (1) The licensee shall take measures to keep the center free of flies, other insects, and rodents.

Reporting Requirement 101212 (d)(1)(C), (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event, (1) Events reported shall include the following: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.

The interviews conducted during the Case Management inspection on June 16, 2026, revealed C1 did not make direct contact with the snake, facility took immediate action by evacuating the children from the playground, no other children made direct contact with the snake, and the facility called the snake services to remove the snake from the facility.

During this office meeting he facility has been issued a Technical Violation for Personal Rights 101223(a)(2): The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

Director provided photos of the yard being done to make it safer from having snakes enter the playground area. The photos provided demonstrate the fencing to have a snake fence and areas with concrete or grass bottom opening of the fence is also covered with the snake fence. The bottom of the fence that's near the mountain the photo demonstrates wood board to cover the bottom opening. The two sheds located in the playground play area, the photos demonstrate a gate fence to the back and front. Director stated the doors on the playhouses have been removed to prevent snakes hiding. Director explained how the outdoor daily checks are being conducted by having staff use a broom or stick to move toys around and inside the toy bins. The broom or stick is also used to hit structures to hear any rattling noise or to see any movement. Director mentioned the playhouses, have been removed from fencing area and placed in the middle of the playground. Director stated a daily outdoor check list will be provided to staff to ensure the daily checks are being conducted including raking areas of concerns prior to children coming out to play to ensure there is no hazards out in the playground area.

Exit interview conducted and report was reviewed with President Brenda Rubin and Director Carol Bloom.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Mayra Rivera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
LIC809 (FAS) - (06/04)
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