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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360906559
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:08:14 PM

Document Has Been Signed on 08/09/2023 03:08 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:CSUSB CHILDREN'S CENTERFACILITY NUMBER:
360906559
ADMINISTRATOR:DEANNA HERNDONFACILITY TYPE:
850
ADDRESS:5500 UNIVERSITY PARKWAYTELEPHONE:
(909) 537-5928
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 15DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Deanna BrownTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Maddox met with Director Deanna Brown today to conduct a Case Management inspection regarding an Unusual Incident that occurred on 8/7/2023. A written report has been received.

Description of the incident:
ON 8/7/2023, the children from the "Pups" (preschool) classroom were outside on the playground. There were eleven children and 3 teachers present on the yard. One teacher went inside to get the table ready for lunchtime, leaving 2 teachers on the yard with 11 children. 2 children got wet from water play, so one of the teachers brought the 2 children inside to change their clothing. At this time, the teachers assumed there were 10 children total (there were actually 11). Staff #1 lined the children up and counted 10 children before bringing them inside. Once they were brought inside, a teacher in the other classroom saw the 11th child (child #1) standing outside the door and brought her in. Staff estimate it was approximately 2 to 3 minutes


Based on information provided and interviews conducted, a Type B citation will be issued today for violation of Section 101229 Responsibility for Providing Care and Supervision. This incident did not warrant a Type A citation due to the time child #1 was outside and that the play yard is secured and child was not able to leave the yard. Exit interview conducted and a copy of report provided to Director, Deanna Brown
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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 08/09/2023 03:08 PM - It Cannot Be Edited


Created By: Donna Maddox On 08/09/2023 at 02:53 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: CSUSB CHILDREN'S CENTER
FACILITY NUMBER: 360906559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time, Supervision shall include visual observation.
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Director states a training will be provided to staff referencing Supervision.
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This requirement was not met as evidenced by child #1 was left on the play yard unsupervised for
approximately 2 - 3 min.
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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:Donna Maddox
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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