367700179-3-28-2023-12-CC-KZIS-CQCTY9-20230328150822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 367700179
Report Date: 03/28/2023
Date Signed: 03/28/2023 03:08:49 PM

Document Has Been Signed on 03/28/2023 03:08 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:	WILLIAMS FAMILY CHILD CARE		FACILITY NUMBER:	367700179
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 6	CENSUS: 7	DATE:	03/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Licensee, Jackie Williams		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Zirbes met with Licensee, Jackie Williams, who guided analyst on a tour of the facility for the One Year Required inspection. This is a one story, three bedroom, two bathroom home with kitchen/dining, living area, and detached garage. There are no pool/spa or body of water on the premises. Family members residing in the home include licensee, and four children ages (3 months, 6, 9, 11). Upon arrival LPA observed seven children in care. Current days and hours of operation are Monday thru Saturday, 24 hours a day. Physical Plant: Child care is provided in the living area (left of entrance), the family room, hallway bathroom, and backyard. Off limit areas include all bedrooms, kitchen, dining room, and the detached garage. The off limit areas were made inaccessible via child safety gates and child safety door knobs covers and key lock on the master bedroom door. One of the off limit bedroom doors was closed however was missing the child safety door knob cover, therefore the off limit bedroom was potentially accessible. Per conversation with the Licensee the door knob cover recently broke. LPA provided the Licensee with a technical advisory notice and reminded the Licensee that all off limit areas had to be made inaccessible to the child care children. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines, and hazardous items, that can pose a danger to children. LPA observed medications, and cleaning products in the hallway closet locked with a key locked. LPA observed Clorox (cleaner and bleach), Microban (all purpose cleaner), Clorox toilet cleaner, glass cleaner and Scrubbie Bubbles bathroom cleaner stored in an unlocked closet in the entrance way. The chemicals were stored on the lower areas of the closet. The children were engaged in table top activities 12 -14 feet away from the closet with the chemicals. The closet door was immediately locked by the Licensee during the safety inspection. A technical advisory notice was provided. Fire/earthquake drills was last completed in January 2023. Documentation is maintained and up to date Report continued on page two

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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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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: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 03/28/2023

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Report continued from page one
LPA observed a 2A10BC fire extinguisher in the kitchen. According to the Licensee the fire extinguisher was provided by CCRC within the past year. LPA advised the Licensee to keep documentation that the fire extinguisher had been serviced or purchased within the year, to ensure compliance with the State Fire Marshall requirements.

Safe and age appropriate toys, play equipment and materials. The smoke detector and carbon monoxide detector, were tested. When first tested the carbon monoxide detector had a blinking red light and did not make a sound when the "test" button was pressed. Licensee adjusted the battery and the carbon monoxide detector beeped when the test button was pressed. LPA advised the Licensee to continually check the carbon monoxide detector to ensure the equipment is in operating condition. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed in the on limit area. A baby bouncer was observed in the off limit area of the home and LPA reminded the Licensee that the equipment can not be present in the areas where child care is provided and can not be utilized during childcare hours. The family room dining room is the designated area for ill children in the child care. There are age appropriate napping equipment, (cots, play yard, and crib).

Per Licensee, there are no weapons or firearms on the premise. In addition, LPA did not observe any weapons in the home. The home has a fireplace in the child care room, which was surrounded by a fire place gate. Home has central AC and heat.

Bathroom: Shower/tub free of hazards. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Toilet and faucet are clean and operable.

Outdoor: The backyard is completely fenced. The backyard was equipped with a trampoline and a swing set. The trampoline and swings were placed on grass. LPA observed an approximate 12 inch section of the pad covering the springs on the trampoline was torn and ripped. The trampoline had safety enclosure net to prevent the children from falling off the trampoline. Licensee stated the trampoline has not been utilized in over a month due to the winter weather. LPA observed five metal pipes in a stack in the outdoor play area. LPA advised the Licensee to move the metal pipes to an off limit area. LPA provided the Licensee with a technical advisory notices. LPA and Licensee discussed active supervision and safety when the trampoline is being used by the children. Report continued on page three

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 03/28/2023

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LPA observed two dogs and three puppies present during this inspection. Per Licensee the dogs do not interact with the child care children. Per License, dogs are current on shots and licensing.

CPR/First Aid expires 03/05/25 and mandated reporter training expired 10/20/2022.

LPA reviewed three child files, and the Licensee file. Based on LPAs record review one of the three child files reviewed was missing the LIC 995A. A technical advisory notice was provided. Per LPAs record review of the Licensees file mandated reporter training expired in 10/20/22, a type B citation was issued, as this poses a potential risk, refer to LIC 809

Documents Provided and/or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep.
The following were observed: Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Emergency and Disaster Information (LIC610A). LPA observed the roster was missing the names and information of the newly enrolled children and the end date for disenrolled children. An advisory notice was provided.

The following was discussed with the licensee:

Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Licensee reminded that 100% supervision is required at all times to children in care. Licensee was made aware that it is he/her responsibility to know the regulations as well as anyone who assists in providing care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified
The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Report continued on page three

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 03/28/2023

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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-and-resources/safe-sleep as an additional resource. 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.

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. 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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process

Based on LPAs record review there were seven technical advisory notices issued today and one type B citation. Refer to LIC 809D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Jackie Williams

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2023 03:08 PM - It Cannot Be Edited

Created By: Kendal Zirbes On 03/28/2023 at 01:56 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: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one of one staff file (licensees) reviewed did not have a current mandated reporter training. The Licensee training expired 10/20/2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2023
	Plan of Correction
1 2 3 4	Per Licensee, the mandated reporter training will be completed and a copy of the certificate will be submitted ti CCL.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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