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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411390
Report Date: 09/13/2023
Date Signed: 09/13/2023 10:36:27 AM

Document Has Been Signed on 09/13/2023 10:36 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:LANCASTER UNITED METHODIST CHILDRENS CENTERFACILITY NUMBER:
197411390
ADMINISTRATOR:MEDINA, NICOLEFACILITY TYPE:
830
ADDRESS:918 W. AVE JTELEPHONE:
(661) 942-0812
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 15DATE:
09/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Director Nicole MedinaTIME COMPLETED:
10:45 AM
NARRATIVE
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On 9/13/2023 at 8:37am, Licensing Program Analysts (LPA) Andrea Pittman conducted an unannounced case management visit at the facility and was met by Director Nicole Medina who permitted entry to the facility. LPA toured the facility with the Director according to the facility sketch. Upon arrival, LPA observed 15 children with 5 staff members providing care and supervision.

On 7/21/2023, the Director submitted a LIC 624- Unusual Incident Report stating that they had to terminate a teacher for creating an unsafe environment for infants in care as Staff 4 handled the children in an unsafe manner. After observations, interviews, and record reviews, the following information was revealed about the weeks leading up to the submission of the LIC 624-Unusual Incident Report:

During this investigation, LPA received pertinent documents related to this investigation, which included the facility’s staff and children’s rosters, personnel records, and other relevant investigation documents. It was revealed that Staff 4 violated the personal rights of three children: Child 1, Child 2, and Child 3. Staff 4 tossed a ball at Child 1 to prevent them from awakening another sleeping infant, hitting Child 1 in the head. Staff 4 did not come to assist Child 2 and assess the infant after the infant had fallen from an infant climbing structure. And, Staff 4 grabbed Child 3 by their feet and briefly held the infant upside down while playing. This is a Type B violation, see the LIC 809D for the details.

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SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LANCASTER UNITED METHODIST CHILDRENS CENTER
FACILITY NUMBER: 197411390
VISIT DATE: 09/13/2023
NARRATIVE
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Additionally, on 7/24/2023, the LPA visited the facility to inquire about the incidents that transpired between the children and Staff 4. It was discovered in each of the three children’s file that there was no incident report documenting the incidents that occurred between the children and Staff 4. The LPA inquired of Staff 3 if the parents of the children had been notified of the incidents. Staff 3 stated that the parents were not yet notified. During the visit on 7/24/2023, the LPA informed Staff 3 that the incidents needed to be included in each child’s file and the parents of the children needed to be notified. On 9/8/2023, LPA spoke with two parents of the three children involved in the incidents with Staff 4, the parents were unaware of the incidents and had not been notified by the Licensee. The failure to notify the parents is a Type B violation, see the LIC 809D for the details.

An exit interview was conducted, and a copy of this report was provided to Director along with the Notice of Site Visit and Appeal Rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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Document Has Been Signed on 09/13/2023 10:36 AM - It Cannot Be Edited


Created By: Andrea Pittman On 09/13/2023 at 09:43 AM
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: LANCASTER UNITED METHODIST CHILDRENS CENTER
FACILITY NUMBER: 197411390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2023
Section Cited
CCR
101223(a)(1)

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101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights:(1) To be accorded dignity... personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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Director conducted a meeting and training to address personal rights. This was previously completed by the Director and verification was sent on 7/26/2023.
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Based on observations, interviews, and record reviews, the Licensee did not comply with the section cited above as the Staff 4 violated the rights of Child 1, Child 2, and Child 3 while in care which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/27/2023
Section Cited
CCR101212(f)

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101212 Reporting Requirements
(f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.

This requirement was not met as evidenced by:
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Director conducted a meeting and training to address meeting reporting requirements. This was previously completed by the Director and verification was sent on 7/26/2023.
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Based on observations, interviews, and record reviews, the Licensee did not comply with the section cited above as the Licensee did not notify the parents of the incidents involving their children after notifying licensing of the unusual incident which poses a potential health, safety or personal rights risk to persons 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:Andrea Pittman
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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