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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750130
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:39:56 PM

Document Has Been Signed on 03/07/2024 04:39 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:PURE & SIMPLE ACADEMY INC.FACILITY NUMBER:
197750130
ADMINISTRATOR:SANDRA LONA AGUIRREFACILITY TYPE:
830
ADDRESS:43301 DIVISION ST. SUITE 101TELEPHONE:
(661) 524-1042
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 58TOTAL ENROLLED CHILDREN: 58CENSUS: 11DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Deborah CastilloTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted a case management inspection at Pure and Simple Academy Inc. LPA met with Director Deborah Castillo. LPA stated purpose of the inspection was to follow-up on a self-reported Unusual Incident Report (UIR) that happened on 02/29/2024 at the center. The investigation included an inspection of the facility where the incident occurred, a review of the video, facility records, and confidential interviews with staff members. LPA was provided with copies of Name to Face Transition Sheet and the Children’s Attendance dated 02/29/2024.

On 03/01/2024, LPA received a link to the video, copy of the UIR, and Disciplinary Action documents for Teacher 1 (Teacher 1, T1).

During this visit, LPA observed 11 children with 2 staff member providing care and supervision. Teacher to child ratio was also met.

Based on the information gathered and the recorded video provided, the incident happened at 10:30 A.M.
during outdoor play and at the front of room 304 (Toddlers Room). There are four children present and one staff member (Teacher 2, T2) providing care and supervision to children. While T2 was writing her notes, child 1 (C1) was having tantrums and wanted to go inside room 304. T2 tried to hold C1 from getting inside room 304. T1 who was inside room 304 and preparing for children’s nap time, grabbed the child’s hands and walked him out to the bench.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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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: PURE & SIMPLE ACADEMY INC.
FACILITY NUMBER: 197750130
VISIT DATE: 03/07/2024
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Pg 2

Based on the evidence gathered, no deficiencies were cited as a result of this self-reported unusual incident report.

A LIC 9213 Notice of Site Visit was left at facility and must be posted for 30 days. Failure to do so will result in an immediate civil penalty assessment of $100.00.

An exit interview was conducted, Appeal Rights and a copy of this report were provided to Director Deborah Castillo.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Joselito DelMundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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