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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700249
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:37:40 PM

Document Has Been Signed on 04/26/2023 12:37 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:KOHLER FAMILY CHILD CAREFACILITY NUMBER:
367700249
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
04/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Laura Kohler, LicenseeTIME COMPLETED:
12:00 PM
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On April 26, 2023, Licensing Program Analyst (LPA), Kuliema Calloway made an unannounced Case Management Inspection visit to the above Family Child Care Home. LPA met with Licensee assistant who granted access. The purpose of the inspection was to inform the licensee that on 2/27/2023, there was an Unusual Incident that occurred between Staff 1 and Child 1 inside the Family Childcare Home and the licensee failed to report the incident to Community Care Licensing Division.

A Type B deficiency was cited issued during this visit. Per Title 22, Division 6, HSC,1597.467 (b) (1) (C) for Reporting Requirements. See 809 D for deficiency cited. A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified using the unusual incident form (LIC 624).

Exit interview was conducted and a copy of this report, Notice of Site Visit, and Appeals Rights were discussed and provided to the licensee. A Notice of Site visit was posted and must remain posted for 30 days. Removal of posting is subject to a $100 civil penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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Document Has Been Signed on 04/26/2023 12:37 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 04/26/2023 at 11:21 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: KOHLER FAMILY CHILD CARE
FACILITY NUMBER: 367700249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited
HSC
1597.467(b)(1)(C)

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1597.467 (b) (1)(C) A report shall be made to the dept. via telephone or fax... during.. normal business hrs... before the close...following the occurrence ...during the operation..(C)...incident...that threatens ...physical/emotional...safety...child. This reqmnt was not met as evidenced by:
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Licensee will provide a written declaration to the Department stating Reporting Requirements were added to the facility's Plan of Operations and submit the declaration to the Department by the date of: 5/5/2023.
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Based on record review and observation licensee did not provide a report to the Department via telphone, fax, or email regarding the incident that occurred with Staff 1 and Child 1 on 2/27/2023 within 24 hours of the incident occurring.
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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: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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