<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409258
Report Date: 06/27/2024
Date Signed: 07/01/2024 09:44:18 AM

Document Has Been Signed on 07/01/2024 09:44 AM - 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:PEREZ FAMILY CHILD CAREFACILITY NUMBER:
197409258
ADMINISTRATOR/
DIRECTOR:		PEREZ, ESTHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 264-4016
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
06/27/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Esther PerezTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On June 27, 2024, at 9:20 A.M., Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted an unannounced annual inspection at Perez Family Child Care Home to assess its ability to meet compliance with California Code of Regulations (CCR) Title 22, Health, and Safety requirements. LPA met with the licensee, Esther Perez. LPA Del Mundo stated the reason for the inspection. LPA was granted access to the facility. The LPA provided copies of the LIC 126 Entrance Checklist Form, LIC 311D Forms/Records to Keep in the Family Child Care Home, and all records/forms that need to be maintain in the facility. Licensee guided the analyst on a tour of the day care areas. The day care take place in the following area of the home: attached converted garage (main care room), bathroom #1, and backyard (outdoor play area). Licensing fees are current.

Licensee states the day care hours of operation is 23 hours, seven days a week. Currently living in the home is the licensee and licensee’s spouse. Licensee is providing transportation to children in care only when needed. Licensee has current California Driver’s License, vehicle registration, and car insurance. During this visit, LPA observed four children present in the facility. Based on the Facility Roster, licensee has seven children enrolled in the day care.

Physical Plant: The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children. The smoke detector and carbon monoxide detector are in operable conditions (tested at 11:44 A.M.). The facility has a fully charge fire extinguisher with a 3-A:40-B:C classification (reading in green, checked at 11:40 A.M.) and meets the State Fire Marshall standards. Licensee stated that she owns no firearms, and no one smokes in the facility. LPA observed cleaning products and detergents are stored in one of the rooms of the facility which is off limits to children in care. Per licensee, knives are stored in the kitchen cabinets. The kitchen (off limits) has a child safety wooden gate that separates it from the main care room. Per licensee, household medications are stored to
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 07/01/2024 09:44 AM - It Cannot Be Edited


Created By: Joselito DelMundo On 06/27/2024 at 12:46 PM
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility did not comply with the section cited above by failing to conduct fire/disaster drill which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
Licensee will email a copy of the fire/disaster drills conducted to LPA.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility did not comply with the section cited above by failing to provide the LIC995 Notification of Parents’ Right for child 1, 3, and 5 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
Licensee will email copies of the signed parents LIC995 Notification of Parents’ Right for child 1, 3, and 5 to LPA.
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:Lady King
LICENSING EVALUATOR NAME:Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 07/01/2024 09:44 AM - It Cannot Be Edited


Created By: Joselito DelMundo On 06/27/2024 at 12:46 PM
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by failing to maintain a copy of LIC 627 Consent for Emergency Medical Treatment for child 3 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
Licensee will email a copy of signed parents LIC 627 Consent for Emergency Medical Treatment for child 3 to LPA.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility did not comply with the section cited above by failing to provide the signed parents LIC282 Affidavit Regarding Liability Insurance for child 1 and 5 which posed a potential Health, Safety or Personal Rights risk to persons in care..
POC Due Date: 07/15/2024
Plan of Correction
1
2
3
4
Licensee will email copies of signed parents LIC282 Affidavit Regarding Liability Insurance for child 1 and 5 to LPA.
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:Lady King
LICENSING EVALUATOR NAME:Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 06/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg 2

children in care.

The facility is a one-story house. There is no fireplace in the main care room. The home has central heating and air conditioning units.


Based on records review, the fire/earthquake drills were not conducted. Licensee was reminded to conduct fire/earthquake drills once every six months.



Safe and age-appropriate toys, children’s books, dolls, wooden blocks, cubbies, table, and chairs were observed during the inspection. LPA observed a closet, refrigerator, drawer, office table, and office chair in the main care room. LPA also observed sleeping cots for children to use during nap time.

Licensee has first aid kit box placed on top of the shelve above the drawer.

Licensee is advised that baby bouncers, saucer chairs, or any recalled and or banned toys or sleep/ play equipment are prohibited on the premises. Licensee is advised to check for fixture, furniture and equipment that have been banned or recalled by the United States Consumer Product Safety Commission.

Bathroom: Toilet, sink and faucet were clean and operable. LPA did not observed razors and/or sharp objects, shampoos, mouthwash, medications, perfumes, air freshener, nail polish and nail remover that will pose a health and safety risk to children in care. LPA observed a step stool inside the bathroom.



Licensee stated that when a child shows signs of illness, the child is separated from other children and sit on the office chair.

Outdoor: The facility has no body of water on the premises. The outdoor play area has a small, covered porch and age-appropriate toys and play equipment. The backyard has on and off-limits area. LPA observed 3 swing sets, climber, trampoline, and a basketball hoop in the on limits area.

At the time of inspection, Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing on the day of the incident and/or 24 hours of incident by telephone, fax
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 06/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg 3

and/or in writing to the Department. Licensee is familiar with the Unusual Incident Report form, LIC624B. The report on unusual incident/injuries can also be mailed to unusualIncidentreport@dss.ca.gov

Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA reviewed five children’s files and the licensee’s files. Based on records review, three of the five children’s files have missing licensing forms. Licensee has current mandated reporter training certificate dated August 8, 2023. Licensee has current CPR/First Aid trainings certificate dated March 28, 2023. Licensee has proof of immunization against Measles and Pertussis. Licensee has Influenza vaccine and TB skin test on file.

Licensee and other adult living in the home have received criminal record clearance.

The following was discussed with the licensee:

Mandatory licensing forms such as LIC 311D Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; The applicant was reminded that 100% supervision is required at all times to children in care; Applicant was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care.

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). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.

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.



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 06/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg 4

webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep 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.

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. 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

Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations. Our Quarterly updates come out every 3 months and are also 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



The applicant was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) requires all licensed providers, applicants, directors, and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicants must meet requirements as a precondition to licensure. New

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 06/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg 5

employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com.

Prior to making alterations or additions to a family childcare home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "childcare" room; Room additions to the family childcare home. Any change from an area of the family childcare home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition, or construction.


Lead Flyer Requirement Health and Safety Code 1596.7996 mandated that effective January 1, 2019, CCC's and FCCH's are required to provide parents and guardians of children enrolling or reenrolling in care with written information on the risks and effects of lead exposure, blood lead testing requirements and recommendations, and options for locations of affordable blood lead tests as specified. A Lead Poisoning Facts Flyer was created, in partnership with the California Department of Public Health (CDPH), to satisfy this requirement.

The applicant was advised it is her responsibility to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov

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 them by email to: inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the CCLD website at: https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.




The Licensee is informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: PEREZ FAMILY CHILD CARE
FACILITY NUMBER: 197409258
VISIT DATE: 06/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pg 6

The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM to 5:00 PM.

The facility is not in compliance per Title 22 regulations. During today's inspection, LPA Del Mundo observed deficiencies that may hinder the health and safety of the children in care. Type B deficiencies were cited during this inspection. An exit Interview and discussion of observations were conducted with the licensee.



During the exit interview the licensee Esther Perez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Notice of Site Visit: A Notice of Site Visit (LIC 9213 was given and must remain posted for 30 days.
Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

A copy of this Report was reviewed, and Appeal Rights were also provided to Licensee, Esther Perez.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8