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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700110
Report Date: 04/14/2026
Date Signed: 04/14/2026 02:07:05 PM

Document Has Been Signed on 04/14/2026 02:07 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:DUOBERT-CHUMBE FAMILY CHILD CAREFACILITY NUMBER:
197700110
ADMINISTRATOR/
DIRECTOR:		DUOBERT-CHUMBEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 478-8581
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
04/14/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:59 AM
MET WITH:Mercedes Duobert-Chumbe, Licensee TIME VISIT/
INSPECTION COMPLETED:
02:02 PM
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On 04/14/2026, Licensing Program Analyst (LPA) Justeene Tamayo conducted an unannounced annual/random inspection and met with licensee, Mercedes Duobert-Chumbe who guided LPA on a tour of the facility. This is a two story home with 4 bedrooms, 3 bathrooms, a kitchen, a family room, a living room/dining room, a den, a laundry room, a garage, and a backyard. The garage is used for storage only and no childcare activities are conducted there. Family members residing in the home have a fingerprint clearance and associated, and have TB on file. LPA observed 2 preschool age children present in the home with Licensee and assistant #1 caring for them. Operating hours are Monday to Sunday, 24 hours a day as needed. LPA reviewed the overnight care regulations with the licensee, discussed her supervision plan, and provided her with a copy of Title 22, Division 12, Chapter 3, Article 6 – Section 102426 (Overnight Care). Per licensee, currently no IMS is provided at this time.

Areas off limits to children include- Bedrooms #2-4, bathrooms #2-3, all upstairs spaces, garage, laundry room, and front yard.

LPA Tamayo inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Tamayo observed central AC and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA did not observe any fire places in the home.

LPA Tamayo observed cleaning compounds items, stored in the upper kitchen pantry, which has a door with operable safety. LPA observed the knives/sharp objects in upper kitchen pantry, out of reach to children in care. Medication is stored in the upper kitchen cabinet with a safety latch. Per licensee, breakfast, lunch, snacks, and dinner are provided. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any children with severe food allergies nor on medication. Licensee is a participant in a food program.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2026
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: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 04/14/2026
NARRATIVE
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Bathroom: LPA Tamayo observed the toilet, hand washing sink, hand soap in the child care bathroom. The bottom sink cabinet did not have any accessible hazardous materials observed. The child care bathroom observed to be in good condition. LPA reminded licensee, personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Tamayo observed the required 2A10BC fire extinguisher located outside of bedroom #1 and the valve on the green area indicating fully charged. LPA observed a carbon monoxide detector and smoke alarm located in the living/family room. LPA tested the carbon monoxide and smoke alarm and observed to be in operable condition. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic


wipes and located outside of bedroom #1. There is an isolation area for children who become ill while in care as needed. Last Fire/Disaster drill was completed on 04/01/2026.

Outdoor: Children play in the back yard. LPA toured the porch 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. There is a jungle gym anchored and in safe condition. There is also an empty koi pond in the back yard. The empty pond is surrounded by chain link fence (declaration in file).Per licensee, there are 3 dogs in the home. Licensee stated there are no guns, weapons, or firearms in the home.

Licensee's First Aid/CPR expires on 04/18/2026. Licensee's mandated reporter training expires on 06/18/2026. Licensee was reminded she must retake her CPR and First aid and mandated reporter training before expiration dates.

LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, LIC 610A Emergency Disaster Plan, Pub 394 Notification of Parents Rights, and LIC 999 Facility sketch. LPA also reviewed children’s roster, children files including sleep logs and staff files.

During file review, assistant #1 did not have proof of negative TB shot with poses a potential risk to day care children in care. Facility has been cited a Type B citation. Please see LIC809-D for deficiency page. During file review, assistant #1 did not have proof of mandated reporter training. Technical Violation (TV) given. Licensee will send proof of TB and mandated reporter training for assistant #1 no later than 04/28/26.

During file review, child #1 was missing proof of immunization's, which poses a potential risk to day care children in care. Licensee will send proof of immunization's for child #1 no later than 04/28/26. Facility has been cited a Type B Citation. Licensee will also have parents sign the LIC700 and LIC627 for child #1. Technical Violation (TV) given.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110
VISIT DATE: 04/14/2026
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Criminal Record Clearance - Family Child Care Homes Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Safe Sleep - Child Care Centers and Family Child Care Homes LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

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/.

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

Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Facility has been cited 2 type B Citations and 2 Technical Violations given during today's inspection.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted, and report was reviewed with the licensee Mercedes Duobert-Chumbe, along with a copy of her appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Justeene Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2026 02:07 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 04/14/2026 at 01:36 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: DUOBERT-CHUMBE FAMILY CHILD CARE
FACILITY NUMBER: 197700110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Assistant #1 did not have proof of negative TB vaccination, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Licensee will send proof of negative TB vaccination for assistant #1 no later than 04/28/26.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, he licensee did not comply with the section cited above. Child #1 did not have proof of immunizations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Licensee will send proof of immunizations for child #1 no later than 04/28/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Justeene Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2026


LIC809 (FAS) - (06/04)
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