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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492985
Report Date: 03/13/2026
Date Signed: 03/13/2026 12:09:37 PM

Document Has Been Signed on 03/13/2026 12:09 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:HERNANDEZ FAMILY CHILD CAREFACILITY NUMBER:
197492985
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 793-6987
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
03/13/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Dolores Hernandez, Licensee TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 03/13/2026, Licensing Program Analyst (LPA) Justeene Tamayo conducted an unannounced case management inspection to inspect the new detached dwelling unit. LPA met with Licensee Dolores Hernandez. Licensee is requesting to use the dwelling unit for child care in the afternoons at this time. Per licensee, the day care children will be using the rooms inside of the home during drop off around 7AM-12PM. Children will then be utilizing inside of the dwelling unit from 12:15PM to close of business. Licensee's operation hours are less than 24 hours Monday-Sunday. LPA observed 1 infant and two preschool age children, along with assistant #1.

Per licensee she will be utilizing the same areas inside of her home for child care as follows: The living room and playroom(toddlers) area near the backyard, the bathroom in hallway on the right hand side, as well as the living room and dining room area. Off limit areas include all bedrooms, bathrooms #2 and #3 (upstairs), laundry room (garage), and garage(key locked).

LPA inspected the detached Junior Accessory Dwelling Unit located in licensee's backyard 155 E R-3 Avenue, Unit #B, Palmdale CA 93550. LPA obtained a Certificate of Occupancy from Building and Safety finalized and dated 02/10/2026. LPA observed wooden flooring inside of the unit. There is a small kitchen(with working kitchen faucet), refrigerator, kitchen stove, microwave, and working bathroom that obtains a shower, toilet, and bathroom sink for day care children to utilize. There are plenty of toys and small tables for children to utilize. There are two TV's installed. There are cots and playpens for sleeping children. LPA observed a working smoke and carbon monoxide detector, 2A10BC fire extinguisher, and a pull fire alarm. There is a glass sliding door that has a latched lock. There is also another blue door that is key locked on the left side of the dwelling unit.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HERNANDEZ FAMILY CHILD CARE
FACILITY NUMBER: 197492985
VISIT DATE: 03/13/2026
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Licensee is informed LPA will send final dwelling unit inspection report and pictures to LPM for review and approval. Licensee is informed to continue to operate inside of her home until the dwelling unit is approved. Licensee understood.

An exit interview was conducted, and a copy of this report was read and provided to licensee on this date, along with a copy of Notice of Site Visit and appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
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