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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415591
Report Date: 11/05/2025
Date Signed: 11/05/2025 02:22:14 PM

Document Has Been Signed on 11/05/2025 02:22 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:POWELL FAMILY CHILD CAREFACILITY NUMBER:
197415591
ADMINISTRATOR/
DIRECTOR:		POWELL, ANTOINETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 802-6841
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
11/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Antoinette Powell. LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On November 5, 2025, Licensing Program Analyst (LPA) Annelise Villa met Licensee Antoinette Powell guided analyst on a tour of the facility for the random annual inspection. Upon arrival, LPA observed 10 children in care in care with Licensee and 1 assistant caring for them. Family members living in the home are Licensee and 1 minor child. Hours of operation are 7:00 am to 5:00 pm Monday through Friday. Incidental Medical Services (IMS) policy was discussed. No children in the daycare with IMS.

Physical Plant: This is a two-story 6 bedrooms, 3.5 bathrooms home with kitchen, living room, family room, dining room, garage which Is converted a daycare area, front/back yards, and laundry room. The primary care is conducted in the daycare area. The off-limit areas of the home include bedrooms #1-6, bathroom #2-4, kitchen, living room, dining room, all upstairs areas, and the front yard. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, and medicines. Hazardous items (sharp knives, cleaning detergents/compounds, and medications are stored in an off limits area) are inaccessible to children in care.

Safe and age-appropriate toys, play equipment and materials were observed. LPA tested the smoke detector and carbon monoxide detector and observed both to be in operable condition. Fire extinguisher (2A10BC) was observed in operable condition in the hallway area near the hallway. Electrical outlets were inaccessible. No recalled and or prohibited toys or play equipment were observed on the premises. There is a designated area for ill children as necessary.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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: POWELL FAMILY CHILD CARE
FACILITY NUMBER: 197415591
VISIT DATE: 11/05/2025
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Bathroom: Bathroom #1 located in the daycare area. Bathroom #1 is a half bath with no shower and no tub. The toilet and sink are in operable condition. LPA did not observe any hazardous material in the bathroom. LPA reminded applicant the children's bathroom must be free of accessible shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover.

Kitchen: The kitchen is off limits to children in care. The home has a clean and fully stocked refrigerator/freezer in the daycare area. Breakfast, lunch, and snacks are provided, as needed. Licensee stated she is a participant in a food program.



Outdoor: Children play in a portion of the back yard. The back yard is sectioned off with a 6 foot tall gate. LPA toured the back yard and observed it to be free of garden tools, poisonous plants, thorn trees, cactus, or lawn mower inaccessible to children. The play area is clear and clean of debris, play area is fenced and gated all around. LPA observed age-appropriate play equipment for children.

Pools/Spas/Bodies of Water: There are no pools, spas, or bodies of water on the premises.

Advisory/Other: First Aid kit was observed with supplies readily available in the daycare area. Licensee’s First Aid/CPR is valid and expires on 10/9/2027. Licensee’s Mandated Reporter training is valid and expires 12/27/2026. LPA reminded licensee mandated reporter training and First Aid/CPR must be completed every 2 years. Licensee was advised online First Aid/CPR courses cannot be accepted and all in person courses must be EMSA approved. For more information about First Aid/CPR courses, please visit, https://emsa.ca.gov/childcare_provider/. Per Licensee there are no pets in the home. Licensee stated there are no guns, weapons, or firearms in the home. Additionally, Licensee stated there is no smoking of any kind in the home. Last fire/disaster drill was conducted on 10/15/2025.

Licensee’s annual fees are current. LPA observed all required facility postings on premises. Licensee had the following required posted documents: Notice of Parent's Rights Poster (PUB 394), Facility License (LIC 203) and Fire/Disaster Log. Licensee was reminded to post Emergency Disaster Plan (LIC 610A) in a prominent place.

Documents Provided and or Discussed: Earthquake Preparedness Checklist (LIC 9148), Safe Sleep PIN 20-24-CCP and Individual Sleeping Plan (LIC9227).

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
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: POWELL FAMILY CHILD CARE
FACILITY NUMBER: 197415591
VISIT DATE: 11/05/2025
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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.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Licensee shall permit the Department to inspect the family childcare home, and to privately interview children or staff, to determine compliance with or to prevent violations of family childcare laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

Licensee advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

Prior to making alterations or additions to a family childcare home or grounds, the Licensee shall notify the Department of the proposed changes, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" 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. 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.



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep. More information on Infant Safe Sleep procedures can be found online on the CDSS web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs 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.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
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: POWELL FAMILY CHILD CARE
FACILITY NUMBER: 197415591
VISIT DATE: 11/05/2025
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/. The Department will convey all new information through PINs. Please sign up to be notified here and visit the Department’s website for the latest PINs.

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

During the exit interview, Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPAs completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey will 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 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 Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted, and report was reviewed with the licensee. A notice of site visit was given and must remain posted for 30 days. No citation was given today as a result of this inspection.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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