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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700179
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:59:14 PM

Document Has Been Signed on 06/13/2024 03:59 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 CAREFACILITY NUMBER:
367700179
ADMINISTRATOR/
DIRECTOR:		JACKIE WILLIAMSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 531-6006
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Licensee Jackie Williams and Facility Representative Clarice Williams TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On June 13, 2024, Licensing Program Analyst (LPA) Zirbes conducted an unannounced case management inspection to Williams Family Child Care. LPA met with facility representative Clarice Williams. Upon arrival, LPA observed staff 1 (S1) providing supervision to a total of 11 children The Licensee arrived to the home at approximately 11:30am. At 1:03 pm, S1 and three children (one infant, one preschool and one school age child) left the family child care. Therefore the family child care was brought into ratio.

During the inspection, LPA requested to review the facility records, which included the facility roster and S1 file. Facility records revealed S1 was supervising one infant (child 1), five preschool age children (child 2, child 3, child 6, child 7, child 8) and three school age children, (child 4, child 5, child 9). Two of the children observed being supervised by S1,(child 10 and child 11) do not count in the ratio as child 10 and child 11 are over the age of 10 and reside in the home. S1 and the Licensee confirmed the number of children in care. This family child care is a large family child care, however since S1 was alone and providing supervision without an assistant, the licensee shall comply with the capacity requirements for a Small family Child Care and can not exceed a capacity of eight children. Based on LPAs record review, observation, and interviews, the family child care was out of capacity and ratio when LPA arrived to the home. Therefore the facility is being cited a type A citation for regulation 102416.5 (e) Staffing Ratio and Capacity. This poses a immediate risk to the children in care. Refer to LIC 809D.
During the inspection, the Licensee was unable to provide LPA with S1s personnel record. When LPA asked if S1 had pediatric cardiopulmonary resuscitation (CPR) and pediatric first aid training, the Licensee stated S1 did not have CRP/First Aid training. LPA observed S1 alone and providing supervision to the child care children therefore S1 was required to have training in CPR/First aid. A type B citation was issued for regulation, 102416(c) Personnel Requirements, refer to LIC 809D. During the inspection, LPA interviewed S1 regarding how long S1 had worked at the family child care. S1 stated a few weeks. The Licensee confirmed S1 has worked at the family child care for a few weeks. Report continued on page two
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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: 06/13/2024
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Report continued from page one

In addition, LPA asked S1 and the Licensee for paperwork regarding S1 background clearance. Licensee and S1 could not provide documentation of S1 background clearance. At 12:13pm LPA completed a search of the Department records which revealed S1's background is in progress, therefore S1 does not have a eligible clearance. Prior to employment or initial presence in the child care home, S1 an employee for more than a few weeks did not obtain a California clearance as required. A type A citation was issued for regulation, 102370 (d) (1) Criminal Record Clearance, as this poses a immediate risk to the children in care. Refer to LIC 809D. Furthermore, in accordance with regulation 102370 (e) Criminal Record Clearance, an immediate assessment of a civil penalty of one hundred dollars ($100) per day for a maximum of five days has been issued as S1 was working at the child care for a few weeks.

LPA Zirbes informed Licensee, Jackie Williams that this report dated June 13, 2024, documents two Type A citations which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Zirbes informed the Licensee to provide a copy of this licensing report dated June 13, 2024, that documents any Type A citation 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 this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An exit interview was conducted, and this report and appeal rights were reviewed with Licensee Jackie Williams. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/13/2024 03:59 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 06/13/2024 at 02:05 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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
102416.5(e)

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102416.5 (e) Staffing Ratio and Capacity: If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home...This requirement is not met as evidence by: .
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Per Licensee, the family child care as brought into capacity during this inspection. Licensee will hire additional staff. Licensee will review the capacity requirements and review the Department videos. Documentation that the videos have been reviewed will be sent to the Department.
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 Based on LPAs record review, observation, and interviews, the family child care was out of capacity on 6.13.24, when S1 was alone and supervising nine children which is more than the small family home capacity of 8. This is an immediate health and safety risk to the persons in care.
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Request Denied
Type A
06/14/2024
Section Cited
CCR102370(d)(1)

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102370 (d) (1) Criminal Record Clearance: (d) All individuals subject to a criminal record review...shall prior to working...licensed facility (1): Obtain a California clearance or a criminal record exemption as required by the Department ... This requirement is not met as evidence by:
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Per Licensee, S1 left the facility during the inspection. S1 will not work at the family child care until S1 obtains a California Clearance. Licensee will ensure all individuals requiring a fingerprint clearance are cleared prior to entering the facility.
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 Based on LPAs record review, observation, and interviews, S1 has been working at the family child care for a few weeks. S1 does not have a California Clearance. This is an immediate health and safety risk to the persons in care. Civil penalties were issued.
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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:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2024 03:59 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 06/13/2024 at 02:38 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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2024
Section Cited
CCR
102416(c)

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102416(c) Personnel Requirements: The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid... This requirement was not met as evidence by:
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Per Licensee, if staff do not have CPR first aid training they will not be left alone with the children.
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Based on LPA observation and interviews, S1 was alone and providing supervision on 6.13.24. S1 has not completed CPR/First Aid training. This poses a potential risk to the persons is 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:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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