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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700280
Report Date: 01/07/2026
Date Signed: 02/10/2026 01:33:57 PM

Document Has Been Signed on 02/10/2026 01:33 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:WALLER FAMILY CHILD CAREFACILITY NUMBER:
367700280
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
01/07/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Shavonda Waller, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 2/10/26, LPA Villa amended the report to reflect off limits garage.
Licensing Program Analyst (LPA) Annelise Villa conducted a Capacity Increase inspection. Upon arrival, LPA met with licensee Shavonda Waller. The requested capacity is 14. The fire department has granted a fire clearance on 12/17/2025. Licensee is advised that as a family childcare home operating at full capacity, she must adhere to the large capacity ratios.

Upon arrival, LPA observed 5 children in care. The family members residing in the home are Licensee, 1 adult, and 4 minor children. Applicant presented evidence of property control. LPA confirmed with applicant that all adults residing and working in the home have criminal record/TB clearances. The facility operates for 23 hours a day, Monday through Sunday with a license capacity of 14 children. LPA reviewed the overnight care regulations with the licensee, discussed her supervision plan, and provided her with a copy of Title 22, Division 12, Chapter 3, Article 6 – Section 102426 (Overnight Care). LPA went over the childcare ratios for a large family home with applicant and provided applicant a copy.

Physical Plant: This is a two-story 5-bedroom, 3-bathroom home with kitchen, living room, family room, dining room, upstairs loft, front/back yards, laundry room, and garage. During the visit, Licensee requested to have the converted garage as an accessible area. Per Licensee, children will not eat or sleep in the garage, and will be present in the area for limited amounts of time. The request to add the garage as an accessible area is denied, as Licensee did not obtain permits for the garage conversion. LPA toured the area and did not observe any hazardous items. Children have access to the living room, bathroom #1, and back yard. The off-limits include bedrooms 1-5, kitchen, laundry room, garage, upstairs areas, and front yard. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, and medicines.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WALLER FAMILY CHILD CARE
FACILITY NUMBER: 367700280
VISIT DATE: 01/07/2026
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Hazardous items (sharp knives are located in a kitchen cabinet which has an operable magnetic safety latch, cleaning detergents/compounds are stored underneath the kitchen sink which has an operable magnetic safety latch, and medications were observed to be in a medical lock box in the garage) are inaccessible to children in care. The smoke detector and carbon monoxide detector are in operable condition. LPA observed the required fire extinguisher (2A10BC) is fully charged. Children sleep on cots in the family room. Children eat at tables set up in the family room. The facility sketch is complete and current, there is working telephone (cell phone). Safe and age-appropriate toys, play equipment and materials were observed. Electrical outlets are inaccessible. LPA reminded licensee, no baby bouncer saucer chairs, or any recalled and or prohibited toys or sleep/play equipment are allowed on the premises. There is age appropriate napping (cots) equipment. There are no window cords (tied high) accessible to children. Per Licensee, there are no guns, weapons, or firearms in the home.

Bathroom: Children use bathroom #1 located on the right side of the hallway. Shower was observed to be free of accessible hazards. Bathroom #1 is a full bathroom. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Toilet and faucet are clean and operable.

Kitchen: The home has a clean and fully stocked clean refrigerator/freezer. Breakfast, lunch, dinner, and snacks are be provided. Sharp knives are store in an upper kitchen cabinet. Licensee is advised food brought from the children’s home shall be properly stored, labeled, and dated. Licensee is a participant in a food program.

Outdoor: Children play in the back yard. The play area is clear and clean of debris, play area is fenced and gated all around. LPA observed the outdoor air conditioner in the backyard inaccessible. LPA observed age appropriate toys for children. Children access the back yard through a sliding door in the kitchen and remains locked when children are not outside. LPA observed safe and age-appropriate toys. LPA observed the back yard to be free of garden tools, poisonous plants, thorn trees cactus, or lawn mower inaccessible to children. There are no pools, spas, or bodies of water on the premises.

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. Licensee has a valid CPR/First Aid certification that expires on 3/14/2027, and Mandated Reporter is valid and expires on 6/22-2027. Licensee is reminded First Aid/CPR and Mandated Reporter must be renewed every two years. 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.

NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WALLER FAMILY CHILD CARE
FACILITY NUMBER: 367700280
VISIT DATE: 01/07/2026
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Documents Provided and/or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan (LIC9227), Large Child Care Ratio sheet, and Lead Poisoning flyer's.

The following were observed/discussed and or provided: Seat Belt Safety, Safe Sleep poster observed, forms required for children file (LIC311D), Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Staffing and Ratio (capacity limitations handout provided), Emergency and Disaster Information (LIC610A, LIC9148), Lead Flyer Requirement, liability insurance (LIC282) must have signed form on file if no liability insurance. Names of all adults living in the home: All adults living/residing in the home are fingerprint cleared and associated.

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

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed - related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.


Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter (www.mandatedreporterca.com) were reviewed, to be completed every two years.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WALLER FAMILY CHILD CARE
FACILITY NUMBER: 367700280
VISIT DATE: 01/07/2026
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Licensee advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to part obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Prior to making alterations or additions to a family child care home or grounds, the Licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family childcare home previously identified as "off limits" to an area where care and supervision will be provided to children in care. Licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Licensee shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

LPA discussed the safe sleep regulations with licensee's and also instructed Licensee to visit the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WALLER FAMILY CHILD CARE
FACILITY NUMBER: 367700280
VISIT DATE: 01/07/2026
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Licensee advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

If you have questions regarding this PIN, please contact CPMB at 888-422-5669 or Guardian@dss.ca.gov for assistance.



The Department will convey all new information through PINs. Please sign up to be notified here and visit the Department’s website for the latest PINs.

Ready for licensure for large childcare license.

Exit interview conducted and report was reviewed with Licensee. This report was read and provided to Licensee on this date. Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days. Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Mariela Ramon
NAME OF LICENSING PROGRAM ANALYST: Annelise Villa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC809 (FAS) - (06/04)
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