<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911141
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:06:12 PM

Document Has Been Signed on 03/20/2024 04:06 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:PSD/DEL ROSA HEAD STARTFACILITY NUMBER:
360911141
ADMINISTRATOR:DEBBIE ARNOLDFACILITY TYPE:
850
ADDRESS:2382 DEL ROSA AVENUETELEPHONE:
(909) 883-0103
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY: 63TOTAL ENROLLED CHILDREN: 63CENSUS: 10DATE:
03/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Facility Representative Melissa RagagukgukTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On March 20, 2024, at 01:50 p.m., Licensing Program Analyst (LPA) Zirbes met with Facility Representative Melissa Ragagukguk to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted to the Department on March 7, 2024. The unusual incident report was regarding incident involving child 1 and child 2. As a result of the incident C2 received medical attention due to an injury received from a sensory toy. Upon arrival, there were 10 preschool age children, three teachers, two aides and additional administrator/support staff at the facility.

During this inspection, an interview was conducted with staff 1 (S1). In addition, LPA completed a review of the facility records and child files. LPA was provided with documentation that the sensory tube is recommended for children ages 3-8. At approximately 02:00 p.m, LPA and facility representative conducted a tour of the Center, no deficiencies were observed.

Based on the information obtained through interviews and facility records, the incident does not appear to have been the result of a violation of the Title 22 regulations at this time. However, if additional information is obtained the incident may be re-evaluated by the Department.

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 Melissa Ragagukguk.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1