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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364819975
Report Date: 05/08/2024
Date Signed: 05/08/2024 03:50:44 PM


Document Has Been Signed on 05/08/2024 03:50 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:JOHNSON FAMILY CHILD CAREFACILITY NUMBER:
364819975
ADMINISTRATOR:JOHNSON, SHYIKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 669-0224
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:14CENSUS: 11DATE:
05/08/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Shyika Johnson, LicenseeTIME COMPLETED:
04:00 PM
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On May 8, 2024, Licensing Program Analyst (LPA) Calloway made an unannounced inspection to the above facility. LPA met with Licensee, who granted access. LPA and Licensee toured the home inside and outside for an Annual Random inspection. Residing in the home are the Licensee, Licensee’s spouse, and two minor children. The home is licensed for twelve to fourteen children. LPA observed eleven (11) day care children in care with licensee and two assistants during inspection.
Physical Plant: This is a single story 4-bedroom, 2-bathroom home with kitchen, bonus room, dining area, family room, living room, and garage. Childcare is provided: Living room upon entry, bonus room, and family room next to the kitchen. Children’s Bathroom: is down the hallway on the left it was observed clean, with soap and toilet paper, (no hazards). Unused outlets in the home were covered. Blind cords are cordless. Age-appropriate toys, furniture, and books observed. Napping equipment (cots, playpens, and cribs) observed enough for all children. The home was inspected inside and outside for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, hazardous detergents/cleaning compounds underneath the sink safety latch, in the laundry room in cabinet on high shelf, and on top of the refrigerator. Per licensee there are no medicines inside the home. LPA observed diapers for the infants. Windows screened, free of bugs, cracks, and debris.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364819975
VISIT DATE: 05/08/2024
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Kitchen: items that can pose a danger to children were made inaccessible the kitchen is gated off limits. The sharp knives in a cabinet to the left of the microwave up high. Fire/earthquake drills current (completed April 2024). Child/Parent Roster (current and complete). The required fire extinguisher (2A10BC) (full/green). Smoke and carbon monoxide detectors were tested (operable). Fireplace is fully covered with cubby shelves. Home has central AC and heat. Required postings were present on the wall. There is a landline phone, and cell phone. Fire alarm pull switch was not observed. LPA recommended the alarm be installed and a fire clearance.
Off limit areas: Garage (key lock), Bedrooms: #1, #2, #3, #4 (key locked), Bathroom: #2, and laundry near the garage-not locked but all chemicals are inside the cabinets up high.
Outside: The backyard is completely fenced. Little Tyke toys, bikes, slides, and play equipment. There is artificial grass and concrete for play and the play area is shaded. There is no pool/spa or body of water on the premises. AC unit in the yard was observed covered with a mesh breathable cover.
Others: Per Licensee, there are no weapons or firearms on the premises. LPA did not observe any in the home. Required mandated reporter training (current), CPR/First Aid (Exp: 3/25), and immunizations (current). First Aid kit observed. LPA viewed staff and children’s files and reviewed all infants in care have LIC 9227 form in their files. LPA conducted a staff interview with the licensee. Transportation is provided insurance was verified. Incidental Medical Services (IMS) policy and Safe Sleep regulations were discussed. The following was discussed with the Licensee: Maintain capacity and transparency per posted parent rights, Roster requirements (keep updated information always), Documentation for disaster drills (fire and earthquake). Mandatory forms, signed, for the children’s/staff files, know updated Safe Sleep regulations.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364819975
VISIT DATE: 05/08/2024
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The role and responsibilities of being a mandated reporter. Supervision is always required for children in care. If food is brought in, it is properly labeled. Check food expiration dates periodically. Responsible for knowing the regulations as well as anyone who assists in providing care. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. If day care is closed for the day, no kids show, or Licensee absent, must notify Licensing. Inaccessibility of hazards must be constantly reassessed depending on the children in care. If the phone number is changed, licensing must be notified. Regulations prohibit the smoking of tobacco in a private residence that is licensed as a family childcare home and areas of the day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exer saucers, and any other items that fall into that category.

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. Type A deficiency: Type A deficiency shall be posted for 30 consecutive days along with the Notice of Site Visit Letter (printed out after every visit) and posted during hours of operation, as there is an immediate risk to the health, safety, or personal rights of children in care. Licensee shall provide a copy any Type A deficiency to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of the Type A report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in the children’s files for verification of the Type A deficiency. Failure to do so will result in a civil penalty being assessed.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364819975
VISIT DATE: 05/08/2024
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--Licensee is advised to visit: www.shotsforschool.org for Immunization information.
--Licensee was informed of their responsibility to report suspected Child Abuse (LIC 9108), 1-800-827-8724/760-243-6640. Licensee was informed of the MyChildCarePlan.org website, a
consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
--Family Child Care Providers (Disaster Planning information):
https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Child Care Videos: https://ccld.childcarevideos.org
--Licensee advised to visit the CCLD website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department prior to providing the IMS. 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: http://www.ada.gov/childqanda.htm.
--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.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364819975
VISIT DATE: 05/08/2024
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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.
--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 inspection process@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.
--Lead Poisoning: For more information, go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600.
Reminder: The On- Duty Worker is available for questions at: (661) 202-3318 (Monday-Friday 8am-5pm) and for reporting Unusual Incident Reports (within 24 hours). Written Unusual Incident Reports are sent (using (LIC 624B form) to the following email address: unusualincidentreport@dss.ca.gov within seven (7) days after reporting the incident via telephone.

Per Title 22 Regulations, Division 12, Chapter 1, there are deficiencies cited during this inspection. See 809D pages attached to this report.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit, Appeal Rights were provided to Licensee, Shyika Johnson during the inspection. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting will result in $100 civil penalty.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 12:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/09/2024 11:57 AM

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: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 364819975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Staff 5 did not have TDAP immunization in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Licensee will provide prove to Licensing by POC date of 5/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Kuliema CallowayTELEPHONE: (661) 202-3381
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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