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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364813612
Report Date: 09/11/2025
Date Signed: 09/11/2025 12:29:17 PM

Document Has Been Signed on 09/11/2025 12:29 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:ACOSTA FAMILY CHILD CAREFACILITY NUMBER:
364813612
ADMINISTRATOR/
DIRECTOR:		ACOSTA, SHANNON & GILBERTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 228-3365
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
09/11/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Licensees Shannon and Gilbert Acosta TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On September 11, 2025, at 09:50 a.m., Licensing Program Analyst (LPA) Zirbes met with Licensee Shannon Acosta who guided analyst on a tour of the home for the Annual/Random inspection. Upon arrival, LPA observed eleven children (six school age and five preschool age children) with the Licensee and two assistants providing supervision. Based on LPA observation, the child care was meeting the staffing/ratio requirements at the time of this inspection. According to the Licensee currently living in the home are the Licensees and two minor children. All adults are associated and have eligible clearances. Current hours of operation are Monday to Friday 6:00am -6:00pm.
Physical Plant: This is a one story, four bedroom, two bathroom home with kitchen/dining, living area, toy room and detached garage. The on limits areas are the toy room, kitchen/dining room, living room, bathroom (located in hallway), and backyard. The off limit areas consist of all bedrooms, the primary bathroom, detached garage and a portion of the backyard. The off limits areas were inaccessible via child safety gate and locked doors. According to the statements of the Licensee there are zero bodies of water on the property. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children. During the inspection, LPA observed cleaning products and medications stored in a magnetic child safe cabinet in the kitchen. Sharp knives were stored on a high inaccessible cabinet. During the inspection the smoke detector and carbon monoxide detector were tested. An audible sound was heard when the items were tested therefore the smoke detector and carbon monoxide detector were found to be operable at this time. A fire place and a wood burning stove were located in the living room. Fire place and wood burning stove were inaccessible via a child safety gate. LPA did not observe baby bouncers/saucer chairs, or any recalled and or prohibited toys on the premises.
Report continued on page two
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 364813612
VISIT DATE: 09/11/2025
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Report continued from page one
Per Licensee, there are firearms stored in the family child care home. According to statements from the Licensee the firearms are stored in accordance with the regulations.

Bathroom: (located in the hallway): Toilet, sink, shower were clean and sanitary. Zero hygiene materials or cleaning products were stored in the bathroom.

Outdoor: The backyard is completely fenced. One section of the outdoor area is off limits and is used by the household pets and household storage. LPA observed a large wooden climbing structure which was secured to the ground and place on sand/dirt. LPA also observed multiple dramatic play houses, trucks cars and geo climber.

Per conversation with the Licensee there are three dogs and three cats in the home. Per Licensee the cats interact with the children and the dogs do not interact with the children.

At the time of this inspection, the exit doors of the Large Family child care met the Fire Marshal Standards.



Record Review: LPA reviewed seven child files, and the Licensees files. Per LPA review of the child care files, all files were complete and contained all required information.


Review of records to be maintained: According to the documentation the fire extinguisher was serviced in 2025. Per recorded documentation the last fire drill was completed in April 2025.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/
safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ACOSTA FAMILY CHILD CARE
FACILITY NUMBER: 364813612
VISIT DATE: 09/11/2025
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Report continued from page two
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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: https://www.ada.gov/resources/child-care-centers/.

During the exit interview, the Licensee Shannon Acosta, confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Based on LPAs record review there were zero citations issued today.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Shannon Acosta.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4