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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364816133
Report Date: 05/22/2025
Date Signed: 05/22/2025 05:22:38 PM

Document Has Been Signed on 05/22/2025 05:22 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:GREEN FAMILY CHILD CAREFACILITY NUMBER:
364816133
ADMINISTRATOR/
DIRECTOR:		GREEN, DOLORESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 949-1905
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/22/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Dolores Green - LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On Thursday, May 22, 2025, Licensing Program Analysts (LPAs) Giovanni Cristales and Mayra Rivera conducted an unannounced annual inspection and met with licensee Dolores Green, who granted access and guided LPAs Cristales and Rivera on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. LPAs did not observe any day care children. Licensee stated she currently does not have any enrolled child care children and only provides care for her grandchildren. Operating hours are Monday to Friday from 5:30 a.m. to 6:30 p.m. Annual fee is current.

This facility is a one-story home that consists of 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, laundry room, garage and front and fenced backyard.

Areas off limits to children include –living room, bedrooms #1, #2, #3 and #4, bathrooms #2 located in the hallway, garage, laundry room, (The laundry room is made inaccessible by a key knob) front yard and back yard. Licensee stated children do not access backyard.

Areas accessible to children include- Family room, kitchen, dining room, bathroom (to the left of the family room).

LPAs Cristales and Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA’S Cristales and Rivera observed central AC/heater, and the vents located on the ceiling along with ceiling fans. LPA’S observed the furniture, children’s materials, to be in good condition and age appropriate.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364816133
VISIT DATE: 05/22/2025
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LPAs observed a fireplace locked with glass doors making it inaccessible to children. LPAs did not observe a play yard. LPAs observed one high chair in the kitchen. Licensee stated currently has no infants in care.

LPAs Cristales and Rivera did not observe cleaning compounds items. Per licensee cleaning compounds/detergent are stored in (off-limit garage and laundry room). Medications are stored in (off-limits, bedroom #2). LPAs observed the knives on top of kitchen counter.

LPAs Cristales and Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap. LPAs observed the bathroom to be in good condition. LPA’S reminded licensee any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPAs Cristales and Rivera asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has no pets, no poisons and no bodies of water, no firearms, and no weapons. LPAs did not observe pets, poisons, firearms, weapons, nor bodies of water. The licensee was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.



LPAs Cristales and Rivera observed the required 2A10BC fire extinguisher located in the kitchen and the valve on the green area indicating fully charged and serviced on 3/12/25. LPA’S observed a dual carbon monoxide detector and smoke alarm located in the hallway next to the bathroom. LPA’S tested the dual carbon monoxide and smoke alarm. LPAs Cristales and Rivera heard the sound and is operable. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA’S observed the last emergency drill conducted on 1/04/2025.

LPAs Cristales and Rivera observed licensee (EMSA) Pediatric First Aid/ CPR certification dated 3/08/2025 and licensee has proof of immunization against Pertussis, MMR, and Influenza. LPAs did not observe licensee’s Child Abuse Mandated Reporting Certification. Licensee stated, she will do the training and provide LPA Cristales a copy by end of the month 5/31/25.

LPAs observed the postings License, LIC 9148 Earthquake Preparedness Checklist, and Pub 394 Notification of Parents Rights. LPAs did not review children’s roster, children files including sleep logs and staff files because there are no children enrolled.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364816133
VISIT DATE: 05/22/2025
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The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2. Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee 80/20 a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.

6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated

7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364816133
VISIT DATE: 05/22/2025
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9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.



12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).

17. Liability Insurance was discussed; LPA’S advised licensee to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.



20. LIC 126 Checklist for Family Child Care provided and reviewed.
NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364816133
VISIT DATE: 05/22/2025
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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.

Licensee Dolores Green 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.

LPAs discussed the safe sleep regulations with licensee Dolores Green 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. LPAs also informed licensee Dolores Green 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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/.

Family Child Care Homes Licensee Dolores Green was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GREEN FAMILY CHILD CARE
FACILITY NUMBER: 364816133
VISIT DATE: 05/22/2025
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Licensee Dolores Green confirmed that there are no Registered Sex Offenders living in the facility and LPA’S completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, no deficiency given during this visit only one technical violation. Please see attachment 9102. Report was reviewed with the licensee Dolores Green.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
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