<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700109
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:26:01 PM

Document Has Been Signed on 10/04/2023 02:26 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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GUEVARA FAMILY CHILD CAREFACILITY NUMBER:
197700109
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jeanette Guevara, LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 4, 2023, Licensing Program Analyst (LPA) Annelise Villa met with Licensee Jeanette Guevara, who guided LPA on a tour of the facility. The purpose of this visit was to conduct a Case Management Incident inspection regarding Child #1 (C1) sustaining a “second degree burn” on their foot. This Unusual Incident was self-reported within the time frame specified by regulations. Upon arrival LPA observed 7 daycare children in care, with Licensee and 1 assistant caring for them.

Description of incident: On 9/27/2023, C1 was dropped off to the FCCH by C1’s older brother at approximately 9:30 a.m. According to the Licensee, there was no mention of any injuries at drop off. At around lunch times, C1 complained of foot pain. Upon inspection, Licensee noticed redness underneath C1’s sock but was not worried. C1 continued to play as usual with no indication pain. After dinner time, C1 complained again of foot pain. When Licensee looked again, a blister had formed on C1s foot. Licensee called C1s parents, who took C1 to the doctor. C1 was then diagnosed with a second-degree burn.

LPA Villa conducted interviews with staff and children involved. At this time, further investigation is needed.
No deficiencies have been cited at this time.

An exit interview was conducted and a copy of this report was provided to the Director, along with a Notice of Site Visit and her appeal rights.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Annelise Villa
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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 1