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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700469
Report Date: 03/03/2025
Date Signed: 03/03/2025 11:32:16 AM

Document Has Been Signed on 03/03/2025 11:32 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:CHURCHILL FAMILY CHILD CAREFACILITY NUMBER:
367700469
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/03/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Jennifer Churchill- ApplicantTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On Monday, March 3, 2025 at 10:47 AM, Licensing Program Analyst (LPA), Braddock met with Applicant(s) for the purpose of conducting a Pre-Licensing Inspection. Applicant and LPA toured the home indoors and outdoors to ensure the home meets licensing requirements. Applicant is requesting to provide care and supervision for a small family childcare home for the capacity of six to eight children. Currently residing in the home is applicant, 6 minor children. All adults residing in the home have a Criminal Record Clearance (DOJ/FBI) and Child Abuse Index Clearance. Applicant is requesting the days and hours of operation will be: 5:30 AM to 5:30 PM. Monday through Friday, for ages 0-12 yrs. Per applicant, no overnight care will be provided.
The Home is set up as follows:
Physical Plant: This is a single-story home with four (4) bedrooms and two (2) bathrooms, a kitchen, living room, dining room, den and garage. The home is inspected for safety, comfort, cleanliness, telephone service, and proper ventilation. There is no landline phone but a cell phone. The home has central heating and air conditioning. LPA recommended that applicant purchase a fan cover for the ac unit . All windows have screens and are free of cracks, bugs, and debris. The kitchen was inspected and was missing plug protectors. All the sharp utensils and knives were stored inside the lower kitchen cabinet with a safety latch. The refrigerator/ freezer are both working. Dining/seating for at least four children were counted.
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SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 03/03/2025
NARRATIVE
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Detergents/cleaning compounds are kept in the off-limits kitchen under the sink (safety latch) or in the laundry room along with medications.
Childcare Area: Per Applicant, the living room will be utilized for the Family Child Care (upon entry). LPA observed age-appropriate furniture, toys, and books for the children. All unused electrical outlets are covered in this area. The isolation area is in den near the front door to the right until the parent can pick up the child. The blind cords are tied up high (cordless).
Child Bathroom: The Bathroom (in the hallway on the left) was toured and inspected the sink/toilet are operable. There were no shampoos, mouthwash, razors, poisons, or medications. The cabinets (locked). The bathroom was clean, sanitized, and in good repair.
Outside: The backyard was inspected. The backyard is fenced all around. There is sand and concrete area for active play. Age -appropriate play equipment. Swing set was anchored. Per applicant, the dogs are vaccinated and will not interact with the day care children.

Bodies of water: There are no bodies of water in the yard.

Off Limit Areas: Bedroom #1 (safety know), Bedroom #2 (baby gate and safety knob), Bedroom #3(safety knob) Bedroom #3 (Baby gate) Kitchen, Bathroom #2, and Garage (locked). Outside area to the right of the backyard on side on the house, where the dogs are kept. Per applicant, the children will not interact with the children
Others: LPA reviewed with [applicant,] 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. page 2
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 03/03/2025
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Entrance Checklist was provided to the applicant.
Current Pediatric CPR/First Aid, Preventive Health and Safety Training, Mandated Reporter, and Immunizations. The Safe Sleeping Regulation was shared with the Applicant. The fire extinguisher (full/green) inside the kitchen. The applicant did not have correct size. Applicant states” that she will order one” . The smoke detectors and carbon monoxide detectors were tested and are operable. Per applicant, there are no weapons or firearms in the home. LPA did not observe any firearms or weapons. The First Aid Kit complete with manual. Incidental Medical Services (IMS) policy was discussed. Transportation will not be provided. The applicant, rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).
The following information was discussed with the Applicant:
Maintain mandatory forms for the children’s files and provider’s files. Requirements for disaster drills (fire and earthquake) and documentation for both. The applicant is reminded that supervision is always required for all children. Maintain capacity limits, parent/child roster maintenance, posting facility license, knowledge of Emergency Plan. All food is properly labeled if brought from child’s home; and all food is checked periodically for expiration dates. Applicant was advised how to access forms and Regulations for Family Child Care online at: www.ccld.ca.gov. Applicant was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Page 3
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 03/03/2025
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 Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified. A licensed childcare provider, administrator, or employee of the licensed child day care facility shall complete an on-line Mandated Reporter Training and shall renew the training every two (2) year at: www.mandatedreporterca.com. Applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form (LIC 624B) and send via email to: www.unusualincidentreport@dss.ca.gov. or via fax. The applicant was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot line at 1-800-540-4000, and also, call the CCLD (Community Care Licensing Division) office and follow up with a written Unusual Incident/Injury Report (LIC 624B). Criminal Record Statement: Applicant, Licensee, or Facility representative] was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is
violated. Safe Sleep: LPA discussed the safe sleep regulations with applicant and discussed 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 applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ Page 4
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 03/03/2025
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and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Notice of Site Visit: A notice of site visit must remain posted for 30 days. Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Parent Notifications Requirements: Per the Health and Safety code (HSC) 1596.859, 1596.8895, and 1597.05 to improve transparency of licensing records and to ensure that the parents/guardians using the licensed childcare facility are aware of situations that present danger to the children. Employees or volunteers at family day care home; immunization requirements; records; exemptions (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, Rubella, Mumps, and Measles. Each employee and volunteer shall receive an Influenza vaccination between August 1 and December 1 of each year. Type A citation: Type A citation(s) shall be posted for 30 consecutive days along with the Notice of Site Visit Letter (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. Applicant 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. The 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). State law prohibits baby walkers, bouncy seats, exer-saucers, and any other items that fall into that category. Applicant was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
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SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 03/03/2025
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Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
On this date, 02/10/25 , the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses.

Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

The On Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM for questions, information, and Unusual Incident Reporting.

A copy of the Safe Sleep Proposed Regulations was provided to the Applicant.

*Incidental Medical Services (IMS) policy was discussed. Applicant 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: Page 6

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 03/03/2025
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 Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Safe Sleep in Child Care: Resources can be found on our website at http://www.cdss.ga.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep.
Lead Poisoning: For more information, go to the California Childhood Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb,or call them at (510) 620-5600. Applicant advised visit www.shotsforschool.org for Immunization information.
Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities,providers, and stakeholders by way of Provider Information Notices
Update Newsletters and other important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/
subscribe and select the Child Care option to receive email communication.

Prior to being licensed, the following corrections are required by: 03/17/25
· Fire extinguisher
· Napping equipment for children
· Stove covers
· A/C unit cover
· Remove fertilizer from back yard or place in off limits area
· Electrical plug outlets for the kitchen area

As a result of this inspection, corrections are needed before a childcare license can be issued. Once the required documents/ photos are received, LPA will submit packet to LPM for approval.


Exit interview conducted this report was read, a Notice of Site Visit, and this report were given to the applicant, and must remain posted on, or immediately adjacent to, the interior side of the main door for thirty (30) days.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
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