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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700179
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:50:02 AM

Document Has Been Signed on 07/23/2024 11:50 AM - 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: 12CENSUS: 7DATE:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Licensee Jackie Williams TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On July 23, 2024, Licensing Program Analyst (LPA) Zirbes conducted an unannounced case management deficiencies inspection to Williams Family Child Care. LPA met with Licensee Jackie Williams. Upon arrival, LPA observed staff 1 (S1) and the Licensee providing supervision to a total of seven children.
On June 13, 2024, LPA Zirbes completed an unannounced inspection. During this inspection, LPA observed one bottle of liquid prescription medication on the Licensees desk in the day care play area. LPA observed two school age children (child 1 and child 2) sitting at tables in day care learning area, approximately 12 feet away from the liquid medication. LPA also observed one infant with the staff member. A barrier was not present separating the day care play area from the day care learning area. Additional preschool children were outside engaged in play. The glass sliding doors separating the day care play area and the outdoor space were closed. LPA observed S1, walk into the off-limit areas of the home while the medication remained on the desk, accessible to the school-age children. LPA observed the liquid medication bottle was half full, and was equipped with a child proof lid. A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D.

During confidential interviews, it was reported A2 has been observed in the home during drop off and pick up on serval occasions and A2, provides care and supervision to the children in care at the facility without a criminal record clearance. The dates of care are unknown. The Licensee denied A2 provides care and supervision to the children. Per Licensee, A2 randomly comes to the home from time to time to fix items around the home. On May 14, 2024, and today LPA and licensee discussed the background clearance requirements. Specifically that all adults prior to employment, or residing in the licensed day care must obtain a background clearance. LPA expressed this includes frequent visitors to the home who have contact with the children in care. On July 22, 2024, LPA Zirbes completed a search of the Guardian System, which revealed A2s background is in process, therefore A2 does not have an eligible clearance.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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: 07/23/2024
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Report continued from page one.
A type A citation was issued for regulation, 102370 (d) (1) Criminal Record Clearance, as this poses an 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)
has been issued.

LPA Zirbes informed Licensee, Jackie Williams that this report dated July 23, 2024, documents one Type A citation 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 July 23, 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 11:50 AM - It Cannot Be Edited


Created By: Kendal Zirbes On 07/23/2024 at 10:46 AM
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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
102370(d)(1)

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102370 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, A2 will not be here during business hours. If a visit is required, A2 will outside of the home in the front yard. All adults requiring fingerprint clearance will obtain clearance prior to initial presence in the home.
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Based on interviews, the licensee did not ensure a California clearance was obtained for A2, prior to A2 providing care and supervision to the child care children, which poses an immediate health and safety risk to the children in 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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/23/2024 11:50 AM - It Cannot Be Edited


Created By: Kendal Zirbes On 07/23/2024 at 10:51 AM
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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
102417(g)(4)

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102417 Operation of a Family Child Care Home (g) The home shall be free from ...(4): …medicines, …which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement was not met as evidence by:
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Per Licensee, medications will be stored in an inaccessible area to all children. Licensee will conduct a staff training regarding storage of medication. A copy of the training will be submitted to the Department by 7/26/24.
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Based on observation, the licensee did not ensure medicine was inaccessible as a prescription bottle of liquid cough syrup was on the Licensee desk in the day care play area accessible to school age children, which poses a potential health and safety risk to children in 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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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