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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 02:03:03 PM

Document Has Been Signed on 05/01/2025 02:03 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: 23DATE:
05/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Jacqueline Gomez, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On May 1, 2025, Licensing Program Analyst (LPA) Annelise Villa met with Site Supervisor Jacqueline Gomez, who guided LPA on a tour of the facility. The purpose of this visit was to conduct a Case Management - Incident inspection regarding an incident that occurred on April 21, 2025. This Unusual Incident was self-reported. LPA discussed reporting requirements, pursuant to California Code of Regulations (CCR) Title 22, Section 101212(d), to ensure all reportable unusual incidents are reported within specified time frames. Upon arrival LPA observed 17 toddler age children and 6 infants in care, along with 7 staff including the director caring for them.

Description of incident #1: On April 21, 2025, daycare children were playing inside, supervised by 5 staff and 1 teacher. Child #1 was playing with large toy cars on the carpet, pushing the toy car. Child #1 ran into a chair and fell over. Child #2 was walking in the area when Child #1 fell over, causing Child #2 to fall on top. Child #1 sustained a lip injury and chipped tooth. The facility treated Child #1’s injury with cool water to clean and contacted parent. Child #2 did not sustain any injury. Interview of staff present revealed there was constant supervision, however, there was no time to prevent the child from running into the chair. No deficiencies were found as a result of the incident. Staff are encouraged to participate in training videos that can be found at https://ccld.childcarevideos.org/child-care-center-operators/.


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)
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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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Description of incident #2: On April 21, 2025, Jacqueline Gomez, Site Supervisor, was preparing the water bottle cart for children for outdoor play. Per Site Supervisor, the cart is stored inside children’s restroom #1 when not in use. Site Supervisor noticed a small tackle box and upon opening, found there were miscellaneous medications inside. Site Supervisor reported the box to the high school campus police, who disposed to the box. Upon further inquiry, it was revealed the box belonged to a staff member who misplaced the box. Due to the medications being unattended in an accessible area of the classroom, the facility was cited a Type B citation in compliance with CCR Title 22, Section 101226(e)(1)(A) Health Related Services, which states Medications shall be kept in a safe place inaccessible to children. The accessible medications are a potential risk/hazard to children in care.

An exit interview was conducted and a copy of this report was provided to the Licensee, along with a Notice of Site Visit and 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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Document Has Been Signed on 05/01/2025 02:03 PM - It Cannot Be Edited


Created By: Annelise Villa On 05/01/2025 at 01:18 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: CAJON HIGH SCHOOL
FACILITY NUMBER: 364808414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
101226(e)(1)(A)

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Health Related Services 101226(e)(1)(A). Medications shall be kept in a safe place inaccessible to children. This requirement was not met as evidenced by: Based on interview and record review, medications were left on a cart in children's restroom #1 and accessible to children in care.
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Site Supervisor shall provide training for staff regarding accessible items and medications in the center.
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This is a Type B deficiency which poses a potential health and safety risk to children 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.
Mariela Ramon
NAME OF LICENSING PROGRAM MANAGER:
Annelise Villa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


LIC809 (FAS) - (06/04)
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