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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808414
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:06:42 PM


Document Has Been Signed on 01/12/2023 03:06 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:CAJON HIGH SCHOOLFACILITY NUMBER:
364808414
ADMINISTRATOR:LATASHIA L KELLYFACILITY TYPE:
830
ADDRESS:1200 W. HILL DRIVETELEPHONE:
(909) 388-6307
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:38CENSUS: 23DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Director Jacqueline GomezTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Maddox met with Lead Teacher, Ms Jackie Gomez today for the purpose of conducting an unannounced Annual/Random inspection. Present today were 7 Infants (3 Staff) and 16 Toddlers (4 Staff). This Infant/Toddler program is held on the grounds of Cajon High School in Infant/Toddler Portable #2. Portable is divided into 2 sides (Infants and Toddlers), center maintains a physical separation. Cribs are kept in a separate area where teachers can still main visual observation. LPA toured the portable modular which consist of 2 bathrooms; main area; kitchenette; and Staff Bathroom. The hours of operation: MONDAY THROUGH FRIDAY 7:00AM TO 5:30PM.

**LPA observed age appropriate furniture, equipment, toys and materials. The classroom was observed to be clean and safe and free of any Health or safety hazards. Telephone service was verified as well as adequate heating, lighting, and ventilation. Drinking water is available inside the classroom in the form of a water coolers. Children's belongings are kept in cubbies.

LPA observed sleep logs depicting 15 min checks, Needs and Service Plans; and Fire Emergency Disaster log
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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 01/12/2023 03:06 PM - It Cannot Be Edited

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: CAJON HIGH SCHOOL
FACILITY NUMBER: 364808414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220

101220 Child's Medical Assessments

(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.
Deficient Practice Statement
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This requirement was not met as evidenced by file review reveals child #2 is missing a Medical Assessment
POC Due Date: 01/26/2023
Plan of Correction
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Staff shall obtain a medical assessement for child #2 by the POC due date, staff shall contact LPA if more time is needed. Staff shall contact LPA via email acknowledging receipt of missing Medical Assessment
Type B
Section Cited
CCR
101238.2


Outdoor Activity Space - (b) The outdoor activity space shall be situated to:

(1) Provide a shaded rest area for the children.
Deficient Practice Statement
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After conducting an inspection of the Physical Plant, LPA noted there is no sufficient shaded rest area for children in care
POC Due Date: 02/02/2023
Plan of Correction
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Staff shall contact LPA with a plan to obtain additional sufficient shade for Infants and Toddlers in care.
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 KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


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: CAJON HIGH SCHOOL
FACILITY NUMBER: 364808414
VISIT DATE: 01/12/2023
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**Food preparation area/Kitchenette was inspected for safety, cleanliness, proper equipment & protection against contamination and storage. Center serves breakfast and lunch, menus observed and posted. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children were stored and inaccessible to children. The refrigerator was inspected, LPA observed bottles and Sippy cups labeled with children's names. Allergy List is posted

Licensee reminded of the requirement to report Unusual Incidents (UIR) and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and submit form LIC624B within 7 days of UIR.

**The Parent Board (located in the main entrance area) contained all documents that are required to be posted according to Title 22 Regulations. At least 1 staff person present with current Pediatric CPR and First Aid (exp 4/2019). LPA reviewed a sampling of children files today as part of this inspection. Children's files contain Needs and Service Plans and current immunization's. Sign in and out sheets were inspected and contain full legal signatures. LPA observed a fully stocked first aid kit; fully charged fire extinguishers; carbon monoxide detectors throughout the center. Fire Drill/Earthquake log is posted. Staff files are kept at the San Bernardino District office, staff are fingerprinted through the San Bernardino School District. Teaching Credentials posted for Ms. Jacqueline.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: CAJON HIGH SCHOOL
FACILITY NUMBER: 364808414
VISIT DATE: 01/12/2023
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**The children's bathrooms were inspected; each bathroom has 1 toilet and 1 sink. The staff rest-room is located next to the rear entrance. LPA observed the bathrooms to be clean and sanitary, with soap, toilet paper and paper towels readily available. Toilets and sinks are functioning properly and age appropriate. Changing tables are located within arms reach of a sink.

**Center has stackable cots individually stored so that each child's bedding is identifiable and no child's used bedding comes into contact with other bedding. Each cot is equipped with a sheet to cover the cot and labeled with each child's name. Bedding and linens are laundered weekly and as needed. All flooring and carpets were inspected for cleanliness, and in good repair.

**Outdoor play equipment was inspected for health, safety, good repair and age appropriateness. Center utilizes rubber matting under climbing structures for cushioning material, there are trees on the grass area but no shade on the play yard. The area was observed to be free of debris. Drinking water is brought outside for children. There are no bodies of water observed on the premises. The playground is enclosed by a fence to protect children and to keep them in the outdoor activity area. There is a locked storage shed on the yard that contains children's play equipment and supplies.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: CAJON HIGH SCHOOL
FACILITY NUMBER: 364808414
VISIT DATE: 01/12/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

There were 2 Type B citations issued today. Child #2 missing a Medical Assessment; there is insufficient outdoor shade available for children.

Exit interview conducted and a copy of this report was left at the facility. A copy of this report must be made available to the public for 3 years.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6