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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364819492
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:24:50 PM

Document Has Been Signed on 12/20/2023 01:24 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:KIDS DISCOVERY WORLDFACILITY NUMBER:
364819492
ADMINISTRATOR:MALKANTHI FERNANDOFACILITY TYPE:
850
ADDRESS:15858 BEAR VALLEY ROADTELEPHONE:
(760) 241-2416
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 40DATE:
12/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Micha Hendrix, Center DirectorTIME COMPLETED:
01:30 PM
NARRATIVE
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On December 20, 2023, LPAs Ali and Calloway, made an unannounced case management inspection on the above facility. LPAs met and toured facility with Center Director who granted access. During the inspection LPAs toured the infant room and observed six napping infants and 2 staff. LPAs observed a 6 month old infant napping on there stomach covered with a blanket in a crib. LPAs observed that there was no LIC 9227 sleep plan inside the infant file signed by the parent.

Per Title 22, regulations their are two type A deficiencies cited during this inspection. The two deficiencies are: 101429(a)(2)(B)3a- Responsibility for Providing Care and Supervision for Infants and 101439.1(f)- Infant Care Center Sleeping Equipment.

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 licensing report to parents/guardian 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 licensee will obtain a signed acknowledgement of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Crystal Ali
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 12/20/2023 01:24 PM - It Cannot Be Edited


Created By: Crystal Ali On 12/20/2023 at 12:30 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: KIDS DISCOVERY WORLD
FACILITY NUMBER: 364819492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
101429(a)(2)(B)3a

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101429(a)(2)(B)3a (a)In addition to Section 101229, the following(2)Sleeping
infant(s) shall be directly observed... (B) Staff ...check sleeping infant(s)...3 Infants up to 12 months...a.If the infant’s...LIC 9227...their back for sleeping. This requirement was not met as evidence by:
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Staff will place the infant on their back until LIC 9227 form is received by parents, and provide proof of LIC 9227 to Licensing by POC date of 12/21/2023.
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Based on observation, LPAs observed six month old infant sleeping in crib on their stomach there wasn't an LIC9227 form in the infant file which poses an immediate health, safety, or personal rights risk to the persons in care.
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Type A
12/21/2023
Section Cited
CCR101439.1(f)

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101439.1(f) (f) Cribs shall be free from all loose articles and objects, including blankets and pillows. This requirement was not met as evidence by:



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Staff will remove the blanket and provide and review the Safe Sleep Regulations and provide training to staff and provide proof of training to Licensing by POC date 12/21/2023.
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Based on observation, LPAs observed six month old infant sleeping in crib with blanket covering them. Which poses an immediate health, safey, or personal rights risk to the persons 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:Claretta Yates
LICENSING EVALUATOR NAME:Crystal Ali
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KIDS DISCOVERY WORLD
FACILITY NUMBER: 364819492
VISIT DATE: 12/20/2023
NARRATIVE
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Exit interview was conducted and a copy of this report was read, a notice of site visit and appeal rights were discussed and provided to Micha Hendrix, Center Director at the facility. Failure to maintain posting for the Notice of Site Visit for Thirty (30) consecutive days will result in a $100 Civil Penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Crystal Ali
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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