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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700287
Report Date: 07/11/2025
Date Signed: 07/22/2025 08:54:12 AM

Document Has Been Signed on 07/22/2025 08:54 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 CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:DAVILA FAMILY CHILD CAREFACILITY NUMBER:
367700287
ADMINISTRATOR/
DIRECTOR:
ISABEL DAVILAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 209-6434
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
07/11/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:22 PM
MET WITH:Isabel Davila - LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On Friday July 11. 2025 Licensing Program Analyst’s (LPA’s) Giovanni Cristales, and Calloway met with Licensee, Isabel Davila, who granted access and guided the analysts on a facility tour for an Annual/Random inspection visit to the above facility. LPA’S toured the facility with the Licensee. The licensee is providing care and supervision for a Large Family Child Care for the capacity of 14 children. Present during the time of this inspection were Licensee, and three minor children. All adults living/residing in the home are fingerprint cleared and associated (Licensee, Licensee husband) and 3 minor children. Days/hours of operation are Monday through Friday from 7am to 5pm. Incidental Medical Services (IMS) policy was discussed. Upon arrival, LPA’S observed no children in care.

Physical Plant: This is a single home with 4 bedrooms, 2 bathrooms, kitchen/dining, living room, family room, backyard and garage. The family room is designated as the main childcare area located at the rear of the home and 1 bathroom located in hallway. The play area is clear and clean of debris. Safe and age-appropriate toys, play equipment, and materials. Electrical outlets are inaccessible, and no baby bouncer’s saucer chairs or any recalled or prohibited toys or sleep/play equipment were observed on the premises. Two playpens’ were observed for infant sleep. There is age-appropriate napping (cots) equipment. There are three children’s tables for children to eat. Licensee also utilizes the backyard (fenced in area only to the right). The playing area is composed of turf and dirt flooring, fenced all around, proper playing equipment for children to play with

Off-limits: Living room, Bedrooms #1, 2, 3, and 4, bathroom #2, Kitchen/dining, big portion of backyard (separated by fencing), pool area, volleyball, basketball area, garage and separate storage dwelling (room and bathroom).

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2025
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.

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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: DAVILA FAMILY CHILD CARE
FACILITY NUMBER: 367700287
VISIT DATE: 07/11/2025
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Home is clean and orderly, fireplace is inaccessible, working smoke detector and carbon monoxide detector, operable Fire Extinguisher (2A10BC), no one smokes in the home (sign posted on parent board). There is a designated area for ill child(ren) as necessary (the living room), there are no weapons/firearms in the home, facility sketch complete, current and matches the home.

The home was inspected inside and out for safety, comfort, cleanliness, telephone service, central heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (laundry room), medicines (upper cabinet in hallway), and hazardous items that can pose a danger to children. Fire/earthquake drills were completed and maintained current (04/20/2025). Roster complete and maintained current.

Bathroom: Shower/tub free of hazards. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, and nail polish. The toilet and faucet are clean and operable. LPA’s observed some chemicals stored in the cabinet underneath the sink with a latch.

Kitchen: Sharp items (knives in kitchen upper cabinet ) are inaccessible and the home has a clean fully stocked food refrigerator/freezer. No chemicals in the kitchen were observed to be accessible. Licensee serves Breakfast, lunch and snacks.

Outdoor: The outdoor play area for the children had play equipment that was age appropriate. There was a plastic Little Tikes slide set, grass for cushioned surface and was gated from the rest of the yard. There is a separate storage dwelling room located in the backyard to the right. There is a trampoline in the children's play yard (about 3 ft high from the ground) that is off limits to day care children (the trampoline was observed opened. The Licensee stated their kids were playing in it. There are 2 covered patios in the back yard; built in BBQ pit; 2 standalone BBQ grills. There is a volleyball area with turf flooring, and a basketball court are off limits to the day care children. There are 2 dogs that are kept in off-limit area to the left of the backyard. Per licensee dogs are vaccinated and do not interact with children. There is an in-ground pool in the backyard, the pool was surrounded by wrought iron fencing that is at least 5 ft high, the gate opens away from the pool and there is a spring closure in place and self-latches which are at least 4 ft from the bottom. LPA’s did not observe pool alarm, 12 ft fix pole with body ring, and 17 inch in diameter life ring. Licensee stated they were not aware of the new pool regulations.

Advisory/Other: First Aid kit was observed with supplies readily available. The licensee has CPR/First Aid, expires: 04/16/2026 and the Mandated Reporter Expires: 06/20/27. See LIC 9102. Electrical outlets are inaccessible. There are no window cords accessible to children (string inaccessible).

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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: DAVILA FAMILY CHILD CARE
FACILITY NUMBER: 367700287
VISIT DATE: 07/11/2025
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Advisory/Other: First Aid kit was observed with supplies readily available. The licensee has CPR/First Aid, expires: 04/16/2026 and the Mandated Reporter Expires: 06/20/27. See LIC 9102. Electrical outlets are inaccessible. There are no window cords accessible to children (string inaccessible).

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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following was discussed with the Licensee:

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; Licensee reminded that supervision is required to children in care; Licensee made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the daycare. Per the Licensee no one smokes in the home. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. Licensee advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov.

The license advised of the requirement to report Unusual Incidents. The licensee was 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 the family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

The licensee advised that the Notice of Site Visit must be posted at the entrance of the facility for 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 the 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 the Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met, civil penalties per violation will be assessed.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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: DAVILA FAMILY CHILD CARE
FACILITY NUMBER: 367700287
VISIT DATE: 07/11/2025
NARRATIVE
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Prior to making alterations or additions to a family childcare home or grounds, the Licensee shall notify the Department of the proposed change, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "childcare" room; Room additions to the family childcare 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. The 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.

The licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, before initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, inspect the facility. The Licensee shall permit the Department to inspect the family childcare home and to privately interview children or staff, to determine compliance with or to prevent violations of family childcare 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’S discussed the safe sleep regulations with the licensee and also instructed the 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’S 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. All infants 0-12 months are placed on their backs to sleep unless specified with LIC 9227 form, and no blankets, toys, pacifiers attached and Licensee is monitoring the infants every 15 minutes and maintaining a napping log.

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 platforms.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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: DAVILA FAMILY CHILD CARE
FACILITY NUMBER: 367700287
VISIT DATE: 07/11/2025
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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.

The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8 am-5 pm.

There is one Type A deficiency cited during this inspection, and three Type B deficiencies cited, one technical violation, and one technical advisory. See LIC 809D pages and TV/TA pages attached to this report.

Upon receipt of a Type A deficiency, a copy of the licensing report must also be immediately posted for 30 days. The same report must be provided to the parents/guardians of children to the children in care by the next business day and any newly enrolled at the facility during the next 12 months from the date of the Type A report. The parents must sign LIC 9224 form, and the form shall be placed in all the children’s files and remain for three years. As there is immediate health, safety, or personal rights risks to the persons in care. If these requirements are not met a civil penalty may be assessed.

Exit interview was conducted and a copy of this report was read, this report, Notice of Site Visit, and Appeal Rights were provided to Isabel Davila, Licensee, during this inspection. The Notice of Site Visit must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

NAME OF LICENSING PROGRAM MANAGER: Claretta Yates
NAME OF LICENSING PROGRAM ANALYST: Giovanni Cristales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/22/2025 08:54 AM - It Cannot Be Edited


Created By: Giovanni Cristales On 07/11/2025 at 04:03 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: DAVILA FAMILY CHILD CARE

FACILITY NUMBER: 367700287

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.814(a)(1)(B)(ii)(I)
Pool Safety
(ii) (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.

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 Licensee did not have a pool alarm during the inspection which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 07/12/2025
Plan of Correction
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I will go and buy one tomorrow and install it inside the pool and submit proof to LIcensing by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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.
Claretta Yates
NAME OF LICENSING PROGRAM MANAGER:
Giovanni Cristales
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 08:54 AM - It Cannot Be Edited


Created By: Giovanni Cristales On 07/11/2025 at 04:03 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: DAVILA FAMILY CHILD CARE

FACILITY NUMBER: 367700287

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above in Licensee did not have the life ring for the pool equipment during inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
1
2
3
4
I will check tomorrow for one but will provide proof by POC date
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, the licensee did not comply with the section cited above in Licensee did not have the 12 foot body hook for the pool equipment during inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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2
3
4
I will check to find it tomorrow but will provide proof by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Claretta Yates
NAME OF LICENSING PROGRAM MANAGER:
Giovanni Cristales
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/22/2025 08:54 AM - It Cannot Be Edited


Created By: Giovanni Cristales On 07/11/2025 at 04:03 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: DAVILA FAMILY CHILD CARE

FACILITY NUMBER: 367700287

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's 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).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in C1, C2, C3, C4 did not have the LIC 995 form in their files during inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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2
3
4
I will have the parents sign and provide proof to Licensing by POC date
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Claretta Yates
NAME OF LICENSING PROGRAM MANAGER:
Giovanni Cristales
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
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