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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364814430
Report Date: 04/03/2023
Date Signed: 04/03/2023 03:57:14 PM

Document Has Been Signed on 04/03/2023 03:57 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:PSD YUCCA VALLEY HEAD STARTFACILITY NUMBER:
364814430
ADMINISTRATOR:LUGENE SPRINGFIELDFACILITY TYPE:
850
ADDRESS:56389 PIMA TRAILTELEPHONE:
(760) 369-7424
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 21DATE:
04/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Facility representative, Edna DayTIME COMPLETED:
03:00 PM
NARRATIVE
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On April 3, 2023 Licensing Program Analyst (LPA) Zirbes met with Facility Representative Edna Day for the purpose of conducting an unannounced Case Management incident inspection. The self reported incident occurred at the facility on March 23, 2023. Upon entry to the facility, LPA Zirbes verified twenty one children in care with five staff providing care.

On Thursday, March 23, 2023, the facility, reported Child 1 (C1) (four years of age) wandered from the facility unnoticed by climbing over the facility fence. The facility reported C1 was found on the east side of the field and reported the child did not sustain any injuries.

During the inspection today, LPA interviewed staff, reviewed staff and child files and reviewed video evidence of the incident. At the time of the incident, C1 was in the enclosed outdoor activity space and was under the supervision of Staff 1 (S1) and Staff 2 (S2). According to interviews and video evidence, C1 pushed a approximately three foot high outdoor egg shaped chair against the five foot seven inch cinder block wall that encloses the outdoor activity space. C1 then climbed on top of the chair and over the block wall which allowed C1 to wander away from the Center unsupervised. Video evidence revealed S1 and S2 did not observe C1 climb over the block wall. C1 was found by staff 3 (S3) approximately ten to fifteen minutes later in a driveway of a home located on Palm Ave. C1 file documented that C1 "sometimes elopes". Based on interviews conducted with staff, record review, and video evidence, the facility failed to provide the care and supervision necessary to met C1 needs when C1 wandered away from the facility on March 23, 2023 and was without staff supervision for ten to fifteen minutes. Therefore, California Code of Regulations, Title 22, Division 12, Chapter 1, regulation 101229(a)(1) Responsibility for Providing Care and Supervision, is being cited on the attached LIC 809D.

Report continued on page two

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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 04/03/2023 03:57 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 04/03/2023 at 01:29 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: PSD YUCCA VALLEY HEAD START
FACILITY NUMBER: 364814430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2023
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision ... necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation. This requirement was not met as evidenced by:
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Per facility representative, a written analysis of where the breakdown in current procedures occurred, how we can correct the situation to ensure that this does not happen again, and what measures of monitoring will be implemented to ensure staff is following procedures will be submitted to the Department within 24 hours.
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Based on record review and interviews, C1 climbed over the block wall of the enclosed outdoor activity area, wandered away from the facility and was without the supervision of a teacher for approximately 10 -15 minutes. This posed an immediate risk to the health and safety of 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.
SUPERVISOR'S NAME:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023


LIC809 (FAS) - (06/04)
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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: PSD YUCCA VALLEY HEAD START
FACILITY NUMBER: 364814430
VISIT DATE: 04/03/2023
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Report continued from page one

The licensee is being cited a Type A citation for Responsibility for Providing Care and Supervision. Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility.

This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and the licensee will obtain a signed acknowledgment of Licensing Reports (LIC9224) from the parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An exit Interview was conducted, and a copy of the report and Notice of the Site Visit were read and provided to the Facility representative, Edna Day.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC809 (FAS) - (06/04)
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