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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417974
Report Date: 05/02/2024
Date Signed: 06/05/2024 11:46:51 AM

Document Has Been Signed on 06/05/2024 11:46 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:GUARDIAN ANGEL ACADEMYFACILITY NUMBER:
197417974
ADMINISTRATOR/
DIRECTOR:		ALICIA TORRESFACILITY TYPE:
830
ADDRESS:13413 BRADLEY AVENUETELEPHONE:
(818) 362-2526
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 13TOTAL ENROLLED CHILDREN: 13CENSUS: 6DATE:
05/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Diane H. Ferguson, DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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This is an amended report to a visit conducted on 05/02/2024.

On today's date and time stated above, Licensing Program Analyst (LPA) Isabel Ortega made an unannounced visit for a Case Management visit at Guardian Angel Academy to deliver an amended report for the Case Management report conducted on 05/02/2024. LPA met with Director Diane H. Ferguson to discuss the report.

On 05/02/2024 LPA observed six infants and two staff providing care and supervision to the infants. (LPA) Ortega conducted an observation during nap time in the infant room. Two infants were not on their back during nap time. Although, the facility staff stated the two infants sleeping in face down position, mastered the rolling-over stage, the facility did not provide the Infant Individual Sleeping Plan - LIC 9227 form for the two infants sleeping face down. LPA also, did not observe the safe sleep logs completed for infants 0 up to 2 years. LPA provided the LIC 9227 form and safe sleep logs that may be utilized to record 15 minute checks for all 0 to 2 years of age infants while infants are sleeping.

An exit interview was conducted, a copy of this Report, Appeal Rights, and Notice of Site Visit were provided.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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 06/05/2024 11:48 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/30/2024 09:37 AM


Created By: Isabel Ortega On 05/02/2024 at 02:39 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUARDIAN ANGEL ACADEMY
FACILITY NUMBER: 197417974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/10/2024
Section Cited
CCR
101419.2(b)(2)

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The needs and services plan shall be in writing and shall include the following: Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)]...
This requirement is not met as evidenced by:
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Facility will immediately provide infants representative's the LIC 9227 individual sleeping plan and have the forms returned and Staff will also complete form and submit a copy to the Palmdale Office by email by indicated due date.
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Based on the record review, facility staff did not comply with the section cited above, 2 out of 3 children's files did not have the LIC 9227 Individual Infant Sleeping Plan completed which poses a potential health and safety risk to children in care.
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Request Denied
Type B
05/10/2024
Section Cited
CCR101429(a)(2)(C)

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Responsibility for Providing Care and Supervision for Infants: Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Date, Infant’s name, Time of each 15 minute check, and Initials of the staff person who conducted each check. This requirement is not met as evidenced by:
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Facility will immediately begin to document on logs when infants are napping every 15 minutes and submit the logs to the Palmdale Regional Office by email by indicated due date.
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LPA's observation, interviews and documentation. Two infants did not have any 15 minute log documented. According to staff only 0 to one year of age infants are being documented. This poses a potential health and safety 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:Lady King
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2024 11:49 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/30/2024 10:51 AM


Created By: Isabel Ortega On 05/02/2024 at 04:20 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUARDIAN ANGEL ACADEMY
FACILITY NUMBER: 197417974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/10/2024
Section Cited
CCR
101429(a)(2)(B)(3)

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Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: Infants up to 12 months of age who are sleeping in a position other than on their back. If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, staff shall return the infant to their back for sleeping. This requirement was not met by...
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Facility will immediately begin to turn infants face up until the LIC 9227 individual sleeping plan is completed by infants representative or medical Dr. a copy shall be provided to the Palmdale Regional Office by email by indicated due date.
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Based on the record review, the facility staff did not comply with the section cited above in 2 out of 3 infants whose files were reviewed did not have LIC 9227 completed to state the infant’s ability to roll, which poses a potential health and safety 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:Lady King
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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