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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750023
Report Date: 01/15/2026
Date Signed: 01/15/2026 09:44:19 AM

Document Has Been Signed on 01/15/2026 09:44 AM - 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: 32CENSUS: 15DATE:
01/15/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Facility Representative Christine Britton TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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On January 15, 2026, at 09:11am, Licensing Program Analyst (LPA) Zirbes conducted a case management deficiencies inspection to address information received regarding Lake Los Angeles Elementary School. LPA met with facility representative Christine Britton. Present during today's inspection were 15 preschool children.

Based on a review of the facility records and interviews, the Department discovered a reportable incident occurred on November 17, 2025. Per Administrator, on November 17, 2025, around 12:30pm, child 1 (C1) was left unattended in the children’s restroom. Interviews reported C1 followed staff 1 (S1) and another child into the restroom. S1 did not realize C1 followed S1 into the restroom. S1 left the restroom area and closed the accordion door leaving C1 in the restroom passageway alone and unsupervised. Staff heard C1 knocking on the accordion door and immediately brought C1 into the classroom. Staff 2 (S2) calmed C1 down and provided comfort. Per LPA review of the Departments records, this incident was not reported to the Department. Administrator confirmed the incident was not reported to the Department because C1 did not leave the school grounds and C1 was alone for a minute or less. Based on record review and interviews, on November 17, 2025, C1 was left alone and unsupervised in the restroom area, this was an unusual incident that potentially threatened the emotional health and safety of C1 and therefore this was a reportable incident. A type B citation for regulation 101229 (a)(1) Responsibility for Providing Care and Supervision and one type B citation for regulation 101212 (d)(1)(C) Reporting Requirements is being issued as this was a potential risk to the children in care. Refer to LIC 809D.

Notice of Site Visit was given and must remain posted for 30 days. An exit interview was conducted with facility representative, Christine Britton . Appeal rights and a copy of the report were provided to facility representative, Christine Britton.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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Document Has Been Signed on 01/15/2026 09:44 AM - It Cannot Be Edited


Created By: Kendal Zirbes On 01/15/2026 at 09:12 AM
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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision…
(1): No child(ren) shall be left without the supervision of a teacher at any time…Supervision shall include visual observation. This requirement was not met as evidenced by:
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Per facility representative a staff training and a review of the supervision protocols was completed prior to this inspection. A copy of the training will be submitted to the Department by 1.22.26.
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Based on interviews on November 17, 2025, C1 was left without the supervision of a teacher or aide in the restroom area. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
01/22/2026
Section Cited
CCR101212(d)(1)(C)

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101212 Reporting Requirements (d)... during the operation of the childcare center of any of the events… (1) Events reported shall include… (C) Any unusual incident… threatens the … emotional health or safety of any child. This requirement was not met as evidenced by: Per record review and
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Per facility representative the Administrative staff will send a plan of correction to the Department by 1/22/26.
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interviews on November 17,2025, C1 was left without the supervision of an adult which threatened the emotional health of C1, this unusual incident was not reported to the Department as required. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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