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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808413
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:37:09 PM

Document Has Been Signed on 12/06/2022 12:37 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:SAN BERNARDINO CHILD DEVELOPMENT CENTERFACILITY NUMBER:
364808413
ADMINISTRATOR:LATASHIA KELLYFACILITY TYPE:
830
ADDRESS:2350 N. E STREETTELEPHONE:
(909) 388-6307
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY: 34TOTAL ENROLLED CHILDREN: 34CENSUS: 15DATE:
12/06/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Site Supervisor Annabell Lopez MaganaTIME COMPLETED:
12:45 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 December 6, 2022 at 09:25 am Licensing Program Analyst (LPA) Zirbes met with the Site Supervisor Annabell Lopez Magana. The purpose of the inspection was to conduct an unannounced case management annual continuation inspection. During the inspection, LPA toured and inspected the Infant/toddler program in accordance with the facility sketch. LPA observed a total of 15 children (three infants, and 12 toddlers) with two teachers and four aides providing supervision.

During the inspection LPA reviewed ten child file (three infants records and seven toddler files). Based on LPA review eight of the ten child files reviewed were missing a signed consent form for emergency medical treatment (LIC 627). This poses a potential risk to the children in care. Furthermore based LPAs review three of three infant files reviewed did not have a Needs and Service Plan completed prior to the infants first day at the Center. A technical violation was issued.

LPA reviewed four staff files. Based on LPAs review, the staff files contained all required information.
During the inspection LPA reviewed the electronic sign in records. Records were complete.

Based on LPAs observations one type B citation for regulation 101221(b)(8)(C) Child's Records and one technical violation for regulation 101419.2(a) Children Records was issued today. Refer to LIC 809D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Site Supervisor, Annabell Lopez Magana
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
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)
Page: 1 of 3
Document Has Been Signed on 12/06/2022 12:37 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 12/06/2022 at 12:07 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: SAN BERNARDINO CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 364808413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in eight of ten child files reviewed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2022
Plan of Correction
1
2
3
4
Per facility representaive, the consent form for emergency medical treatment will be added to each file.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3