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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911141
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:11:04 PM

Document Has Been Signed on 03/20/2024 04:11 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: 5DATE:
03/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH: Facility Representative Melissa RagagukgukTIME COMPLETED:
04:20 PM
NARRATIVE
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On March 20, 2024, Licensing Program Analyst (LPA) Zirbes conducted a case management deficiencies inspection to address the discovery of incidents that occurred at the facility that were not reported to licensing while conducting facility record reviews.

Records reviewed indicated the center did not submit Unusual Incident Reports (UIRs) to Community Care Licensing (CCL) regarding nine incidents of physical aggression by child 1(C1) between November 2023 – February 2024. Furthermore, the center did not notify the Department of a personal rights violation that occurred on January 18, 2024, between C1 and staff 3 (S3). LPA reviewed the Palmdale Regional Office records, which provided evidence that the center did not report the UIRs via telephone, fax or email to CCL.

A deficiency is being cited based on interviews and records review, in accordance with the California Code of Regulations, Title 22, see LIC 809D.

An exit interview was conducted, and this report was reviewed with facility representative Melissa Ragagukguk. A notice of site visit was given and must remain posted for 30 days.
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)
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Document Has Been Signed on 03/20/2024 04:11 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 03/20/2024 at 02:43 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: PSD/DEL ROSA HEAD START
FACILITY NUMBER: 360911141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements-(d) Upon the occurrence...a report shall be made to the Department...within seven days...(1) Events reported...include the following: (C) Any unusual incident…that threatens the physical or emotional health...of any child. This requirement was not met as evidence by:
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Per Facility Representative, a plan for ensuring the reporting requirements will be met in the future will be submitted to the Department by 4.3.24.
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Based on record review, the licensee did not ensure reporting requirements were adhered to when ten incidents that threatened the physical health of children were not reported CCL, which poses a potential Health, Safety or Personal Rights risk to the 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.
SUPERVISOR'S NAME:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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