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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364808414
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:01:08 PM

Document Has Been Signed on 05/01/2025 02:01 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/
DIRECTOR:		LATASHIA L KELLYFACILITY TYPE:
830
ADDRESS:1200 W. HILL DRIVETELEPHONE:
(909) 388-6307
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 38TOTAL ENROLLED CHILDREN: 38CENSUS: 17DATE:
05/01/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Jacqueline Gomez, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On May 1, 2025, Licensing Program Analyst (LPA) Annelise Villa met with Site Supervisor Jacqueline Gomez, for the Random/Annual inspection. A tour of the facility was conducted. Upon arrival LPA observed 17 toddler age children and 6 infants with 7 staff working under the license including Site Supervisor. Incidental Medical Services (IMS) were discussed.

Indoor/Children’s Area: Childcare center is clean, safe, sanitary and in good repair. There is 1 room available for children. Floors of the classroom have a surface that is safe and clean, cleaning compounds inaccessible, poisons locked, furniture/equipment is good condition, free of flies, other insects, rodents; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, each child has an individual permanent or portable storage space (cubbies, individually labelled with name) for his/her clothing, and personal belongings. Children sleep on cots in the classroom. Each cot is equipped with a sheet to cover the cot and labeled with each child's name. Bedding and linens are laundered daily and as needed. All flooring and carpets were inspected for cleanliness, and in good repair.

Trash cans for solid waste have tight fitting lids and water is provided by the facility. All materials and surfaces are toxic free are inaccessible and there is no fireplace. There are working carbon monoxide detectors, smoke detectors and Fire Extinguishers (3A40BC) located in the near the entrance of the room. There is a working telephone (landline) on the premises. Cleaning chemicals are stored on an upper shelf near restroom #1.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/01/2025
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Restrooms: LPA observed 2 restrooms available for children’s use. Both restrooms are located in the classroom. Restroom #1 is equipped with 1 toilet and 1 sink with a diaper changing station. Restroom #2 is equipped with 1 toilet, and 1 sink. LPA observed the restrooms to be in good condition with working toilets, sinks, hand soap dispenser and paper towels. There is an isolation area for ill children in the classroom.

Outdoor: Children use an outdoor playground for exercise and free play. The play equipment was inspected for health, safety, good repair and age appropriateness. The area was observed to be free of debris, free from hazard, holes, broken items, debris. There are areas for shade and rest. Fencing was observed to enclose the play area. There is poured rubber under the play structure for cushioning.

Pools, spas, bodies of water: There are no pools, spas, or bodies of water on the premises.

Staff/Personnel Records: Designation of Responsibility observed, immunization's, TB clearance, mandated reporter training, Director qualifications, health screening, criminal record statement, and statement acknowledging suspected child abuse were reviewed and maintained current.



Facility Records: Roster, fire/disaster drill log last completed 12/9/2024. Facility was reminded emergency disaster drill must be completed every 6 months. Per Site Supervisor, children’s files are currently being uploaded into an electronic system. LPA was able to review hard copies of children’s files.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty. The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 394L), emergency disaster plan, earthquake preparedness checklist.

Food Service: The facility receives food from the high school cafeteria. The food is delivered daily and transported in warmers to ensure proper food handling and safety. Breakfast, lunch, and snacks are provided. LPA observed the kitchen for the facility to be clean and orderly. There are no sharp knives in the classroom. The facility had the menu posted.


Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 05/01/2025
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Advisory/Other: First aid supplies (thermometer, bandages, scissors) readily available in the classroom near the staff restroom. There is an isolation area for children who become ill while in care as needed. The facility maintains a comfortable temperature at all times, sign in/out sheets available. Smoking is prohibited on the premises, and daily inspection for illness is conducted. Firearms/weapons are not allowed or stored on premises.

Documents Provided and or Discussed: Forms and records to keep at the facility and IMS.

Sign in and out sheets are completed daily at pick up and drop off times. The parent board was reviewed and has all the required forms posted. Fire/earthquake drills current. Roster current. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.

Health Related Services: Site Supervisor is advised all prescription and non-prescription medications must have child’s name and are dated, written consent and instruction from child’s representative, and a plan to document and report to child’s representative when medication is administered to a child; IMS plan was discussed and Director understands when IMS is necessary.

Children are inspected for illnesses (wellness policy) as they arrive. A review of medication policy indicated that prescription medication is administered only with parent's written permission (licensing medication form- LIC9221 - also used). LPA advised the Site Supervisor if the facility will administer medication to document the dosage, date, and time onto a log. Medication can be brought and taken home by the parent daily. Medication will be properly labeled and stored in its original container

Currently, Incidental Medical Services are not provided to children in care. LPA reviewed equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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/childquanda.html

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 05/01/2025
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Site Supervisor advised of the requirement to report Unusual Incidents. Site Supervisor informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of the day care center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. An On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Director shall permit the Department to inspect the family childcare center, and to privately interview children or staff, to determine compliance with or to prevent violations of child care center or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process


A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. No deficiency was cited today.

Exit interview conducted and report was reviewed with the Director. This report was read and provided to along with her appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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