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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700166
Report Date: 08/22/2023
Date Signed: 08/22/2023 06:09:01 PM

Document Has Been Signed on 08/22/2023 06:09 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HENRY FAMILY CHILD CAREFACILITY NUMBER:
197700166
ADMINISTRATOR:HENRY, ELORINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 220-3340
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Elorine HenryTIME COMPLETED:
06:00 PM
NARRATIVE
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On 08/22/2023, at 2:50 P.M., Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted an unannounced annual inspection at Henry Family Child Care Home to assess its ability to meet compliance with California Code of Regulations (CCR) Title 22, Health, and Safety requirements. LPA Del Mundo met with Licensee, Elorine Henry and stated the reason for the inspection. The LPA provided copies of the LIC 126 Entrance Checklist Form, LIC 311D Forms/Records to Keep in the Family Child Care Home, and all records/forms that need to be maintain in the facility. Licensee guided the analyst on a tour of the day care areas. The day care take place in the following area of the home: living room, dining room, family room, kitchen, loft (upstairs) bathroom #1, and backyard (outdoor play area).

Licensee states the day care hours of operation is Monday to Friday from 6:00 A.M. to 6:00 P.M. Currently living in the home is the licensee, licensee’s spouse, and 5 minor children (17, 8, 5, 5, and 2). Licensee is currently providing transportation to children in care. During this visit, LPA observed four children present in the facility.

Physical Plant: The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children. LPA observed all cleaning products and detergents are stored in the laundry area (off limits) and secured with a safety lock. Licensee stated that children are using the kitchen only when they get some water. Knives and other sharp items are stored in the upper shelves of the laundry room (off limits) and secured with a safety lock. Per licensee, household medications are stored in the licensee’s room and zero medications are currently being provided for the current children in care. Licensee stated that she is not a member of the food program, but she is providing three meals and two snacks for children.

The facility is a two-story house. All upstairs room are off limits except for the loft. There is no fireplace in the
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 08/22/2023 06:09 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 08/22/2023 at 04:34 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: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not maintain copies of immunization records for child #2 and #3 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will email copies of immunization records for child #2 and #3 to LPA.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not maintain copies of LIC 995A Notification of Parent's Rights for child #1, #2, #3, and #4 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will email copies of signed parents LIC 995A Notification of Parents’ Rights for child #1, #2, #3 and #4 to LPA.
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:Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


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Document Has Been Signed on 08/22/2023 06:09 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 08/22/2023 at 04:34 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: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not maintain a copy of LIC 700 Identification and Emergency Information for child #1, #2, #3, and #4 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will email copies of signed parents LIC 700 Identification and Emergency Information for child #1, #2, #3 and #4 to LPA.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not maintain copies of LIC 627 Consent for Emergency Medical Treatment for child #1, #2, #3 and #4 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will email copies of signed parents LIC 627 Consent for Emergency Medical Treatment for child #1, #2, #3 and #4 to LPA.
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:Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


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Document Has Been Signed on 08/22/2023 06:09 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 08/22/2023 at 04:34 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: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not maintain copies of LIC 282 Affidavit Regarding Liability Insurance for child #1, #2, #3 and #4 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will email copies of signed parents LIC 282 Affidavit Regarding Liability Insurance for child #1, #2, #3, and #4 to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166
VISIT DATE: 08/22/2023
NARRATIVE
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facility. The home has central heating and air conditioning units.

Based on records review, fire/earthquake drills were last conducted on June 5, 2023, at 3:30 P.M. and is conducted once every six months. The facility has a fully charge fire extinguisher with a 2-A:10-B:C classification (reading in green, checked at 4:04 P.M. LPA observed a doll used by the children present in the day care.



Per licensee, she also provides safe and age-appropriate toys and books. During this inspection, licensee told LPA that they are in the licensee’s room. According to licensee, she provides 15 or 17 sleeping mats for children to use, but they are in the licensee’s room.

Licensee has first aid kit box stored in the cabinet in the master bedroom. The smoke detector and carbon monoxide detector are in operable condition (checked at 4:09 P.M.). LPA observed electrical outlets are covered with a plastic cover to prevent access to children in care. Licensee stated that she owns no firearms, and no one smoke in the facility.

Licensee is advised that baby bouncers, saucer chairs, or any recalled and or banned toys or sleep/ play equipment are prohibited on the premises. Licensee is advised to check for fixture, furniture and equipment that have been banned or recalled by the United States Consumer Product Safety Commission.

Bathroom: Toilet, sink and faucet were clean and operable. During the inspection, LPA did not observed razors and/or sharp objects, shampoos, mouthwash, medications, perfumes, air freshener, nail polish and nail remover that will pose a health and safety risk to children in care.



Currently, the licensee has 6 children enrolled in the facility. Licensee stated that when a child shows signs of illness, he/she is separated from other children in the family room of the facility.

Outdoor: The facility has no body of water on the premises. The outdoor play area has safe age-appropriate toys and play equipment. LPA observed kitchen set toys, scooters, toy cars, and inflatable pools. Licensee is advised to empty the inflatable pools that got filled up during the hurricane Hilary. Per licensee, she supervised children while playing outside.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166
VISIT DATE: 08/22/2023
NARRATIVE
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At the time of inspection, Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing on the day of the incident and/or 24 hours of incident by telephone, fax and/or in writing to the Department. Licensee is familiar with the Unusual Incident Report form, LIC624B. The report on unusual incident/injuries can also be mailed to unusualIncidentreport@dss.ca.gov

Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA reviewed four children’s files and the Licensee file. Based on records review, children’s files are incomplete; licensee has current mandated reporter training completed on 06/08/2022 and CPR/First Aid training that was completed on 09/20/2022. Licensee has proof of immunization against measles, pertussis, and influenza. Licensee also has TB skin test on file.

Licensee and other adults living, working, or associated in the facility have received criminal record clearance except for the licensee’s volunteer (adult #1) which indicated that his background clearance is still in process. Per licensee, adult #1 is not living with her. During this inspection, volunteer is not present in the facility. Licensee presented to LPA the Request for Live Scan Service of adult #1 including the receipt showing that it was paid on 07/27/2022. LPA gave the phone number of the Guardian website to check on the status of her volunteer’s fingerprint clearance. Licensee further stated that adult #1 is not interacting with children in the day care.

The following was discussed with the licensee:

Licensee reminded that 100% supervision is required at all times to children in care. Licensee was made aware that it is he/her responsibility to know the regulations as well as anyone who assists in providing care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified.



The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.

Licensee 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

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HENRY FAMILY CHILD CARE
FACILITY NUMBER: 197700166
VISIT DATE: 08/22/2023
NARRATIVE
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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 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 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 Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM. The facility is not in compliance per Title 22 regulations. During today's inspection, LPA Del Mundo observed deficiencies that may hinder the health and safety of the children in care. Type B deficiencies were cited during this inspection. An exit Interview and discussion of observations were conducted with the licensee.Notice of Site Visit: A Notice of Site Visit (LIC 9213 was given and must remain posted for 30 days.

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


A copy of this Report was reviewed and Appeal Rights were also provided to Licensee, Elorine Henry.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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