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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700211
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:35:00 PM

Document Has Been Signed on 10/09/2023 12:35 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:LUNA FAMILY CHILD CAREFACILITY NUMBER:
367700211
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Maria Luna, LicenseeTIME COMPLETED:
12:45 PM
NARRATIVE
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On October 9, 2023, Licensing Program Analyst (LPA) Calloway met with Licensee, who granted access. LPA and Licensee toured the Luna FCC home for an Annual Random inspection and request for capacity increase. Family members residing in the home include 5 adults (licensee, two sons, friend, and God daughter). The home will be inspected to be licensed for fourteen (14) children. LPA observed three (3) napping children and 3 adults inside the home (Licensee, son, and assistant). Incidental Medical Services (IMS) policy was discussed.
Physical Plant: This is a two story 6-bedroom, 3-bathroom home with kitchen, living room, dining room, and garage (attached/locked). Childcare is provided in Livingroom (upon entry). Children’s Bathroom is in hallway next to the kitchen (observed free from hazards). Unused outlets (covered). Age-appropriate furniture, toys, and books. Napping (cots) equipment for three kids. LPA recommended more cots. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under sink- safety latch), medicines (upper kitchen cabinet- locked container). Kitchen hazardous items that can pose a danger to children (sharp knives in pantry- locked) Fire/earthquake drills (not current). Roster (not current). The required fire extinguisher (2A10BC) (full/green). Smoke detectors and carbon monoxide detectors (operable). Fireplace is screened. LPA recommended safety latch. Home has central AC and heat. Required postings were present on the wall.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211
VISIT DATE: 10/09/2023
NARRATIVE
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Off limit areas: Upstairs: include Bedrooms (#1. #2, #3, #3, #4, #5, #6), Bathroom #2 and #3, laundry room, garage.
Outside: The backyard is completely fenced. Back yard is off limits. No play equipment observed, the yard has rocks covering the ground. AC unit (not covered). Kids will play at the nearby park. There is a turtle, parrot, and three small dogs (vaccinated). Per Licensee, animals do not interact with the day care children, but if kids want to touch the dogs, they are allowed to touch. No pool/spa or body of water on the premises.
Others: Per Licensee, there are no weapons or firearms on the premises. LPA did not observe any in the home. Required training & CPR/First Aid (current). First Aid kit observed (complete). LPA viewed staff and children’s file and conducted a staff interview with the Licensee. Transportation provided (insurance verified). There are facility fees due that must be paid before the capacity increase is granted.
The following was discussed with the Licensee:
Maintain capacity requirements, Notification of Parent's Rights (updated), Roster requirements (keep updated names), Documentation requirements for disaster drills (fire and earthquake). Mandatory forms for the children’s files and provider’s files, updated Safe Sleep regulations were discussed and provided. The role and responsibilities of being a mandated reporter were discussed (Renewal every two years). The licensee reminded that 100% supervision is always required to children in care. If food is brought in, it is properly labeled. Licensee will check food expiration dates periodically. Licensee was advised on how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov. Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211
VISIT DATE: 10/09/2023
NARRATIVE
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 Licensee advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensee must report unusual incidents at unusualincidentreport@dss.ca.gov on LIC 624B for within seven (7) days of occurrence. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified. 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). Type A citation: Type ALetter (printed out after every visit) and posted during hours of operation, as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Licensee shall provide a copy any Type A citation(s) 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. Failure to do so will result in a Civil Penalty being assessed. State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee is advised visit www.shotsforschool.org for Immunization information.

--Licensee was informed of responsibility to report suspected Child Abuse, 1-800-827-8724/760-243-6640


--Family Child Care Providers (Disaster Planning information):https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Child Care Videos: https://ccld.childcarevideos.org
--Licensee advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211
VISIT DATE: 10/09/2023
NARRATIVE
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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
citation(s) shall be posted for 30 consecutive days along with the Notice of Site Visit.

The On Duty Worker is available for questions at (661) 202-3318 Monday-Friday 8am-5pm for information and reporting Unusual Incident reports: @ unusualincidentreport@dss.ca.gov.
LPA discussed (Safe Sleep) during the inspection.

Per Title 22 Regulations, there are deficiencies cited during the inspection. See 809 D pages.

An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit and Appeal Rights were provided to Maria Luna, Licensee. A Notice of Site Visit must remain posted for thirty (30) consecutive days. Failure to maintain the posting will result in a $100 civil penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview], the licensee did not comply with the section cited above in LPA observed one baby walker and two walker toys inside the day care area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2023
Plan of Correction
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Licensee will remove the baby walkers from the day care home by POC date of 10/10/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


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Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Licensee did not have a disaster drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Licensee will provide proof to Licensing of disaster drill by 10/16/23.

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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


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Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in C1 did not have an infant log during inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Licensee will provide an infant log by POC date of 10/16/23 to Licensing.
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
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Based on observation, interview, record review, the licensee did not comply with the section cited above in S2 does not have the Mandated Reporter training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Licensee's assistant will provide proof of Mandated Reporter training by POC date of 10/19/23 to Licensing.
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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in S2 did not have form in files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Licensee will submit proof if signed form by POC date of 10/16/23 to Licensing.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in S2 (Assistant) does not have MMR, TDAP, Influenza which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Licensee will provide proof to Licensing of Immunization by POC date of 10/19/23.
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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in six out of six children were not accounted for on a facility roster which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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3
4
Licensee will provide an updated roster with all childrens names to Licensing by POC date of 10/19/23
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the licensee did not comply with the section cited above in C1 did not have the signed form in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
1
2
3
4
Licensee will provide proof of form signed by parents to Licensing by POC date of 10/18/23

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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 10/09/2023 12:35 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/09/2023 at 12:08 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: LUNA FAMILY CHILD CARE
FACILITY NUMBER: 367700211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in C1 did not have form in their files during inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
1
2
3
4
Licensee will provide proof of the form to Licensing by POC date of 10/11/23
Section Cited
Infant Safe Sleep
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


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