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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750150
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:23:18 PM

Document Has Been Signed on 12/06/2022 12:23 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:ARK ACADEMYFACILITY NUMBER:
197750150
ADMINISTRATOR:VONDA PERRYFACILITY TYPE:
830
ADDRESS:1146 COMMERCE CENTER DRIVETELEPHONE:
(661) 504-4034
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 0DATE:
12/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Vonda Perr and Rivka JonesTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Maddox conducted an announced visit today and met with for the purpose of conducting a second Pre-Licensing inspection for an Infant component. Applicant is requesting licensure for 6 Infants. Consultation provided regarding.

There are 2 rooms designated for Infants (the blue and yellow rooms). During this inspection, LPA observed a changing table located within arms reach of a sink, 1 emergency evacuation crib with 1 additional crib with shelves underneath in the blue room, the yellow room contained age appropriate toys and equipment for Infants.



Owner will store babies belongs underneath shelved baby bed for now, LPA recommending Owner install wall cubbies/shelves in the future.

Recommend parents or staff not enter the Infant room without medical slippers to place over shoes in an effort to prevent epidemics such as hand foot and mouth and to aide in providing a safe and healthy environment for Infants.

Applicant needs to submit a "Needs and service plan" per Title 22, Section 101419.2 - Infant Needs and Services Plan
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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: ARK ACADEMY
FACILITY NUMBER: 197750150
VISIT DATE: 12/06/2022
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LPA printed out the following during this inspection:
Safe Sleep Log
Safe Sleep Regulation Concepts
Form LIC 9227
Regulation 101429 Responsibility for Providing Care and Supervision for Infants

Fire clearance has been received for requested capacity. Exit interview conducted
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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