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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700021
Report Date: 06/08/2022
Date Signed: 06/08/2022 12:29:24 PM

Document Has Been Signed on 06/08/2022 12:29 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:GRIJALVA FAMILY CHILD CAREFACILITY NUMBER:
197700021
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Brigitte Grijalva TIME COMPLETED:
12:43 PM
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Licensing Program Analyst (LPA) Justin Dorsey met with Licensee, Brigitte Grijalva, who guided analyst on a tour of the facility for the One Year Required Inspection. This is a one story 5 bedroom, 2.5 bathroom home with kitchen, dining room area, living room and laundry room. There is no pool on the premises. Upon arrival LPA observed 5 children with the licensee.

Physical Plant: Main care is provided in the living room. Children use the bathroom the homes converted master bedroom. Children have access to the living room, master bedroom and front yard. Off limit areas include the kitchen, 4 bedrooms, 1.5 bathrooms, laundry room and backyard. All off-limit areas in the home are made inaccessible by a child locked door near the living room. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds inaccessible (under kitchen sink), medicines (inaccessible in off limits bathroom) and hazardous items (sharp knives inaccessible on top of the counter) that can pose a danger to children. There is no fireplace in the home. The home has safe and age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector, and Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the master bedroom. Per Licensee there are no weapon/firearms in the home.

The last fire/earthquake drill was completed 03/20/22. Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). Toilet and faucet is clean and operable.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: GRIJALVA FAMILY CHILD CARE
FACILITY NUMBER: 197700021
VISIT DATE: 06/08/2022
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Kitchen: LPA observed the kitchen is made inaccessible by gate. Sharp utensils are inaccessible. Per licensee breakfast, AM snack, lunch, PM snack and dinner are provided. LPA reminded licensee If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. Cleaning supplies are kept under the sink. No chemicals in the kitchen were observed to be accessible.

Outdoor: Children play in the front yard. The front yard is safe for children and completely fenced. Per licensee no cars park in the drive way. The front yard has grass and concrete areas for children to play. LPA observed the toys in the front yard to be in safe condition.

Advisory/Other: First Aid kit was readily available. CPR/First Aid expire 03/15/22. Mandated Reporter was completed 06/28/21. Children nap on mats in the master bedroom.

Documents discussed: Safe Sleep PIN 20-24-CCP, LIC 9227 and Infant Sleep Log.

Licensee Grijalva 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.

LPA discussed the safe sleep regulations with licensee Grijalva and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Grijalva 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.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: GRIJALVA FAMILY CHILD CARE
FACILITY NUMBER: 197700021
VISIT DATE: 06/08/2022
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A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Brigitte Grijalva .

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3