367700179-5-14-2024-12-CC-KZIS-D59U2H-20240514151158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 367700179
Report Date: 05/14/2024
Date Signed: 05/14/2024 03:12:08 PM

Document Has Been Signed on 05/14/2024 03:12 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/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 18	CENSUS: 7	DATE:	05/14/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Licensee Jackie Williams		TIME VISIT/ INSPECTION 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	On 5/14/2024, Licensing Program Analyst (LPA) Zirbes, conducted an Annual/Random inspection and a Case Management Licensee Initiated inspection to assess the home for a capacity increase. LPA met with Licensee, Jackie Williams to ensure the facility meets basic licensing requirements set forth by Title 22, Health and Safety and statutory requirement. The licensee is requesting to provide care for a large family childcare home (FCCH) with a capacity of 14 children. Fire clearance was granted on 4/30/2024. Per licensee, currently residing in the home is the licensee, and four children (1, 7, 10, 12). The Licensee has requested the operating hours be Monday to Friday 5:00 am - 7:00 pm. When LPA arrived to the home, there were six children (one infant and five children over age two), with the Licensee and Adult (A1) providing supervision. During the inspection, one school age child arrived bringing the capacity to seven. Based on LPA observation, the family child care was meeting the capacity and ratio requirements. The home is described as follows: This is a single-story home, with three bedrooms, two bathrooms, kitchen, Day Care Playroom, Day Care Play Area, Day Care Learning Area, detached garage, front and back yard. Per Licensee, child care is provided in Day Care Playroom, Day Care Leaning Area, Day Care Play Area, hallway bathroom and the backyard. Off limit areas include all bedrooms, primary bathroom, kitchen, laundry room, and the detached garage. The off limits areas were inaccessible via child safety gates, child safety door knobs, and locked doors. Indoor: (On limits): Day Care Playroom: LPA observed, a television, educational posters, various toys for the children, a play yard and a fire place. The fire place was inaccessible via a fire place gate. Day Care Play Area: LPA observed a desk for the Licensee, children's cubbies and materials for the child care. Report continued on page two

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 05/14/2024

NARRATIVE

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Report continued from page one
Day Care Learning Area: LPA observed a television, crib and child size tables and chair.

Bathroom 1: Located down the hallway. The bathroom was equipped with a toilet, sink, bathtub, and shower. No hazards items were in the bathroom at the time of this inspection. The bathroom was clean and orderly.

Outdoor play space: The backyard is utilized for outdoor play and is completely fenced. The backyard was equipped with a trampoline and a swing set. The trampoline and swings were placed on grass. The trampoline had safety net to prevent the children from falling off the trampoline. LPA and Licensee discussed active supervision and safety when the trampoline is being used by the children.

Napping equipment: LPA observed two play yards, one crib, mats and cots.
Electrical outlets: All unused electrical outlets are equipped with child safety outlet covers.
Weapons or Firearms: Per Licensee, there are zero firearms or weapons stored in the home.
Cleaning compounds: Stored in the locked closet in the hallway. The items were inaccessible at the time of this inspection.
The smoke detector and a carbon monoxide detector: Located in the hallway of the home. The home has a pull down fire alarm in the entrance way. Smoke detector and carbon monoxide detector were tested at the time of this inspection and found to be in working order.
Fire extinguisher: A 3A40BC fire extinguisher which was purchased within the year was present.
Pet: The family has one dog. Per Licensee, the dog interacts with the child care children. Licensee stated the dog is current on shots and licensing. Licensee has the dogs shot records on file.

LPA reviewed five child files, the Licensees file, and the assistants file. Per LPA review, one of one infant file did not contain the LIC 9227. In addition, LPA observed one school age child arrive to care who was under the age of six. Per information receive from the Licensee, the child's file did not contain documentation verifying the child's enrolment and attendance in kindergarten including transitional kindergarten or elementary school. LPA discussed regulations 102416.5(g) and 102425(c) with the Licensee. Two technical advisory notices were issued based on LPAs child file review. The Licensee and assistants file had the required documentation. Report continued on page three

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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: WILLIAMS FAMILY CHILD CARE	FACILITY NUMBER: 367700179
	VISIT DATE: 05/14/2024

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Report continued from page two

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. Per recorded documentation a emergency drill occurred with in the previous six months.
The following was discussed with the licensee:

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.

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. 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 PIN 22-02-
CCP. 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/.

Licensee 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.

Report continued on page four

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: 05/14/2024

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During the exit interview, the Licensee Jackie Williams, confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

Based on LPAs record review there two technical violations issued today. Approval of the capacity increase is pending final review by a Licensing Program Manager.

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: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC809 (FAS) - (06/04)

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