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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842774
Report Date: 08/16/2023
Date Signed: 08/16/2023 05:31:51 PM

Document Has Been Signed on 08/16/2023 05:31 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:THOMAS FAMILY CHILD CAREFACILITY NUMBER:
364842774
ADMINISTRATOR:THOMAS, DOMEKIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 404-1300
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
08/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:51 PM
MET WITH:Domekia Thomas, LicenseeTIME COMPLETED:
05:30 PM
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On August 16, 2023, Licensing Program Analyst (LPA), Kuliema Calloway made an unannounced Case Management Inspection to the Thomas Family Child Care. LPA met with Licensee who granted access. LPA observed thirteen(13) day care children in active play and two (2) staff.

During the inspection, LPA asked for the child/parent roster. There was a day care child in care since February that was not listed on the facility roster. This is a potential health, safety, or personal rights risks for the persons in care.

Per Title 22 Regulations, Division 12, Chapter 1, There is one (1) Type B deficiency cited during this visit: 102417(8) Operation of a Family Child Care Home.

Exit interview was conducted and a copy of this report was read and a Notice of Site visit were left with Domekia Thomas, Licensee. A Notice of Site visit must remain posted for thirty (30) consecutive days, failure to maintain posting will result in a $100 civil penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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 08/16/2023 05:31 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 08/16/2023 at 05:08 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: THOMAS FAMILY CHILD CARE
FACILITY NUMBER: 364842774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
102417(8)

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102417(8) Operation of a Family Child Care Home- Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.This requirement was not met as evidenced by:
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Licensee will provide a copy of the updated roster to LIcensing by POC date chosen by Licensee of 8/18/2023.
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Based on interview and observation, LPA interviewed a child in day care that was not on the facility roster and according to Licensee, child had been in care since February. This poses a potential health, safety, or personal rights risks to the persons in care. Licensee will provide proof by POC date of 8/18/2023.
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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:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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