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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700166
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:06:55 PM

Document Has Been Signed on 04/30/2024 02:06 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/
DIRECTOR:		HENRY, ELORINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 220-3340
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
04/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Elorine HenryTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 04/26/2024, Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted an unannounced Case Management investigation at the Henry Family Child Care and met with Licensee, Elorine Henry.

During today's inspection, there was one daycare child present with the licensee providing care and supervision. Based on the investigation conducted, licensee stated that she has an adult son who is currently living in the day care. Based on the Guardian roster, licensee’s adult son is not yet fingerprint cleared. The licensee is cited for allowing an uncleared adult to reside in the home. A type A citation will be assessed, as well as an immediate civil penalty of $500.00.

LPA provided the licensee with copies of the LIC9163 including the guidelines on how to fill out the form. LPA informed the licensee to provide a copy of this licensing report dated 4/26/2024 with the Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.



An exit interview was conducted and a copy of this report, Notice of Site Visit, and Appeals Rights were discussed and provided to the licensee, Elorine Henry. A Notice of Site visit was posted and must remain posted for 30 days. Removal of posting is subject to a $100 civil penalty.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 02:06 PM - It Cannot Be Edited


Created By: Joselito DelMundo On 04/30/2024 at 01:38 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2024
Section Cited
CCR
102370

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102370 Criminal Record Clearance
(a) All adults subject to criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: 1) Obtained a Californial clearance or criminal record exception,,.
This requirement is not met as evidenced by:
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Licensee was provided with a copy of LIC9163 to have her son fingerprint cleared. Licensee will send the form to the LPA once the licensee's son has applied for fingerprint clearance.
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According to the licensee, she has an adult son who is living in the facility. Based on Guardian, the adult son is not fingerprint cleared.
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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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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