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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700285
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:07:17 PM

Document Has Been Signed on 06/08/2023 12:07 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:SMITH FAMILY CHILD CAREFACILITY NUMBER:
367700285
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Peggy SmithTIME COMPLETED:
12:22 PM
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Licensing Program Analyst (LPA) Maddox met with Licensee, Peggy Smith today for the purpose of conducting a Required Annual Inspection, Licensee is also requesting to increase her capacity. Licensee guided LPA on a tour of the home which consist of 3 bedrooms, 2 bathrooms, kitchen/dining area, living room; garage, and backyard. The areas designated for child care include the living room, kitchen, 1 bedroom, office, 1 bathroom and the backyard. Off limit areas master bedroom, master bathroom, and garage. Family members residing in the home include (2 adults, applicant and 1 male adult resident). Days/hours of operation will be 7 days a week 23 1/2.

Physical Plant: Home is clean and orderly, fireplace is inaccessible, age appropriate toys and play equipment, working smoke detector and carbon monoxide detector, operable Fire Extinguisher (2A10BC), no one smokes in the home. There is a working telephone on the premises. Cleaning compounds inaccessible to children (located in the washroom in a high cabinet). Medicines are inaccessible to children (located in the master bedroom which is off limits). LPA did not observe any baby walkers or similar items present.


Bathroom: The designated children's bathroom was toured. Toilets and faucets are clean, safe, and operable, bathtub and shower area free of hazard. No medications storage in the medicine cabinet.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 367700285
VISIT DATE: 06/08/2023
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Laundry area: LPA observed cleaning supplies are located at High shelf above the washing machine which made inaccessible to. LPA observed there is no safety lock for the laundry door.
Outside: The LPA toured the back yard and observed age appropriate play equipment, the surface is covered with artificial grass and cement, and the yard is completely fenced in, there are no bodies of water.

Electrical outlets and electrical cord: LPA observed there are several unused electrical outlets and the electrical cord (TV) is hanging which was accessible to children.
The First Aid Kit is in the hallway closet on an upper shelf which made it inaccessible to children. Medications are stored in Master bedroom #1 closet which are made inaccessible to children.
Weapons or Firearms: Per the licensee, there are no weapons or firearms.

Documentation: The licensee has current CPR, First Aid Training (CPR/First Aid expire 11/27/23). The licensee has proof of the required immunization's. The licensee has proof of Mandated Reporting Training exp. 3/9/2025. Licensee does provide transportation. Licensee has maintained a current roster. Children's records were reviewed as part of this inspection.
The following was discussed with the licensee:
Mandatory Forms for the children’s files; Requirements for fire drills, earthquake drills and documentation for both. Role and responsibilities of being a mandated reporter; all person 18 yrs must have a fingerprint clearance prior to presence in the home (licensee's daughter will turn 18 in 2023) Also, the requirement to report any Unusual Incidents (form LIC 624).

Napping equipment (cots): There was 1 infant present that sleeps in a crib.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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: SMITH FAMILY CHILD CARE
FACILITY NUMBER: 367700285
VISIT DATE: 06/08/2023
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**Incidental medical Services (IMS) policy was discussed. licensee will wait until facility opens to determine IMS needs. 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 - None at this time

Licensee is aware of the updated ·Safe Sleep in Child Regulations per 102425Infant Safe Sleep

Kitchen: All sharp utensils and cutlery are located in a high cabinet in the kitchen. , cleaning supplies located in high cabinet in the laundry room.
The smoke detector and carbon monoxide detectors and tested in in operable condition. Fire extinguisher (2A10BC) There is a fully charged fire extinguisher (2A10BC); which meets fire marshal standards.

The On Duty Worker is available for questions at 661-202-3318 Monday through Friday 8am-5pm. There were no violations of Title 22 Regulations noted. Exit Interview conducted a copy of this report is discussed and left at the facility. Fire clearance has been received for the large capacity. LPA printed copy of profile during this inspection.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
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