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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409614
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:31:03 PM

Document Has Been Signed on 11/12/2021 03:31 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:CREATIVE YEARS NURSERY SCHOOLFACILITY NUMBER:
197409614
ADMINISTRATOR:DENISE BAYLISSFACILITY TYPE:
850
ADDRESS:21710 GOLDEN TRIANGLE ROADTELEPHONE:
(661) 254-0718
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY: 187TOTAL ENROLLED CHILDREN: 187CENSUS: DATE:
11/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Cindy LewisTIME COMPLETED:
03:30 PM
NARRATIVE
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On November 12, 2021 Licensing Program Analyst (LPA) King-Lewis met with licensee for the purpose of conducting a Case Management inspection. Upon arrival LPA observed 40 children in care with 6 staff.
On 08-30-21, Licensee and Director notify LPA that the facility created a waiver allowing parents to decide whether they want their child to wear a facial mask or opt-out of the mask mandated. The waiver is signed by children’s parents stating parents choose not to have their child wear a facial mask. The facility is not following the directive from the California Department of Public Health.

During this inspection, the facility was cited a Type B deficiency for Conduct Inimical. Please see Facility Evaluation Report LIC 809D for deficiency cited.

An exit interview was conducted with licensee and appeal rights were discussed and provided. Notice of Site Visit posted. Failure to maintain posted for 30 Days will result in an immediate civil penalty.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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Document Has Been Signed on 11/12/2021 03:31 PM - It Cannot Be Edited


Created By: Lady King On 11/12/2021 at 02:22 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: CREATIVE YEARS NURSERY SCHOOL
FACILITY NUMBER: 197409614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
HSC
1596.885(c)

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Health and Safety Code Section 1596.885(c): Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state. This requirement was not met as evidenced by
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Effective 08-31-21 licensee notified children’s parents that children over the age of 2 years old are encourage to wear facial covering while indoors at the facility.
POC is cleared
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on 08-30-21, licensee and director provided LPA a waiver signed by children’s parents stating parents choose not to have their child wear a facial mask. The facility is not following the directive from the California Department of Public Health. This is a type B deficiency which poses a potential Health, Safety or Personal Rights risk to children in care.
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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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


LIC809 (FAS) - (06/04)
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