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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750023
Report Date: 11/05/2025
Date Signed: 11/05/2025 04:03:21 PM

Document Has Been Signed on 11/05/2025 04:03 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:LAKE LOS ANGELES ELEMENTARY SCHOOLFACILITY NUMBER:
197750023
ADMINISTRATOR/
DIRECTOR:		SUSAN GAINESFACILITY TYPE:
850
ADDRESS:16310 EAST AVENUE QTELEPHONE:
(909) 633-9496
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 24TOTAL ENROLLED CHILDREN: 34CENSUS: 16DATE:
11/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Facility Representative Christine Britton and Director Susan GainesTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On November 5, 2025 at 12:30pm., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced Annual/Random inspection and met with Facility Representative Christine Britton and Director Susan Gaines. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Facility Representative. During the inspection, 16 preschool children, and four staff members were present. The preschool program consists of one classroom (Room 102), bathrooms, and an outdoor play space. The classroom is located on the campus of Lake Los Angeles Elementary school. The preschool program offers two half day sessions. The AM session operates Monday to Friday 8:30 am to 11:30 am; the PM session operates Monday to Friday 12:30-3:30. The Program has a Department approved waiver allowing the program to share the outdoor play space, and bathrooms.
Indoor/Children's Area: Child care center was observed to be clean, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean. Cleaning compounds were stored in a cabinet under a sink that was equipped with a child safety latch. The classroom furniture/equipment was in good condition. Classroom was free of flies, other insects, rodents. The classroom had tables and chairs to meet children’s needs. LPA observed the classroom had a dramatic play area, library and additional areas for instruction. The classroom had diverse play equipment, along with multiple blocks, puzzles and age appropriate materials. Children's belongings are kept in cubbies along the wall as you enter classroom. Trash cans for solid waste have tight fitting lids, drinking water is readily available indoors via cups and bottled water. All materials and surfaces are toxic free, window screens in good repair and free of debris. The classroom was equipped with a carbon monoxide detector. There was working telephone service within the classroom. The facility has central heating and air conditioning and was a comfortable temperature at the time of this inspection. Report continued on page two
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 11/05/2025
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Report continued from page one
LPA observed the first aid kit for the classroom was located in a drawer that was located less than 12 inches from the floor. The child safety latch on the drawer was broken. When LPA opened the drawer, LPA observed approximately five instant cold packs labeled keep out of reach of children. In addition, the first aid kit was also located in this drawer. LPA observed the first aid kit contained antiseptic solution and burn cream. Each of these items were labeled to keep out of reach of children. There was a sign on the drawer indicting the latch was broken. The Director could not recall how long the latch was broken. Based on LPA observation, the first aid kit supplies were accessible to the children in care. Therefore one type B citation was issued for regulation,101226 (d) Refer to LIC 809D. Smoking is prohibited on the premises. LPA did not observe prohibited childcare items during this inspection. Electrical outlets were inaccessible. Firearms/weapons are not allowed or stored on premises. LPA did not observe bodies of water on the premises. Facility Representative confirmed zero firearms/weapons or bodies of water are on the property.
LPA reviewed the centers sign in/out records. Records were complete at the time of this inspection.
Restrooms: The program shares a restroom with the elementary school. There is one boy and one girl restroom. Each restroom was equipped with one toilet. One sink is located outside of the restrooms. The preschool classroom has two additional sink for the children to utilize. Restrooms were observed to be in safe and sanitary operating condition. Toilets and sinks are functioning properly and are age appropriate. Paper towels and soap were available to the children.
Food Service: Food is delivered to the classrooms from the school cafeteria. The AM and PM classes are each served one meal. The menu was posted in the classroom.
Napping: This program offers half day programs therefore the children do not nap. The classroom has an area for quite play.
Outdoor: The outdoor play area was fully enclosed by a fence. LPA observed age appropriate tables and chairs, a climbing structure, swings and various sand toys. The climbing equipment was placed on sand and was securely anchored to the ground. Drinking water was accessible via a pitcher of water and cups.
Facility Records
Emergency drills are being conducted every six months as required.
Child/Personnel Records
LPA reviewed six child records and three personnel files during this inspection. Per LPA review child records were complete and contained all required information.
Report continued on page three
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 11/05/2025
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Report continued from page two Child/Personnel Records continued: Per LPA review, one of three staff files (Staff 1) was missing the health screening. Per LIC 500, S1 has been employed by the facility since 10/8/2024. During this inspection the Director confirmed S1 did not have a health screening and the Director did not know why S1 did not have a health screening. A technical advisory notice was issued. Furthermore, per record review, the Center did not have a personnel record for staff 2 (S2). Per Director, S2 has been working in the Center as a temporary substitute aide for the past two weeks. The Director has requested the required forms from the school district however the documents have not been provided. A technical advisory notice was issued.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.
Facility representative was informed of the 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.
Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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.
To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
As a result of this inspection, one type B citation and two advisory notices were issued. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative Susan Gaines
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2025 04:03 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 11/05/2025 at 12:02 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: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(d)
Health-Related Services 101226 (d): The licensee shall maintain the following first-aid supplies in a location accessible to staff but inaccessible to children:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in when five instant cold pack, anti septic solution and burn cream were located in a drawer that was accessible to the children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2025
Plan of Correction
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Per Facility Representative, the first-aid supplies will be relocated to an area of the classroom that is inaccessible to the children. During this inspection the first aid supplies were relocated to the teacher area. No further action is required.
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.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Kendal Zirbes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2025


LIC809 (FAS) - (06/04)
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