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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700469
Report Date: 05/18/2026
Date Signed: 05/18/2026 02:59:59 PM

Document Has Been Signed on 05/18/2026 02:59 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:CHURCHILL FAMILY CHILD CAREFACILITY NUMBER:
367700469
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
05/18/2026
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:46 AM
MET WITH:Jennifer Churchill, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On Monday 05/18/2026, LPA Isabel Ortega conducted a Case Management
Inspection- Licensee Initiated. Licensee is requesting to increase capacity from a Small Family Childcare home of 8 children to a Large Family Childcare Home with a capacity up to 14 children. LPA announced the purpose of the inspection and was granted entry by Licensee. A tour of the facility was completed, according to the facility sketch. Upon arrival LPA observe eight (8) children in care and Licensee with an Assistant providing care and supervision.
Licensee was initially licensed on 3/18/2025 as a Small Family Childcare Home. The Fire Department has inspected the home and granted a fire clearance for 14 children on 04/27/2026.The operational childcare hours are Monday through Friday from 5:00 p.m. to 5:00 p.m.
This is a one-story single-family home. There is a living room, dining room, kitchen, four bedrooms, den, two restrooms, laundry area, attached garage, and a back yard. Main care is provided in the living room and dining room referred to as the Child Care Play area. Children utilize the restroom to the right from the main entrance of the home. License provides children with cots for napping and infants are provided with a pack and play.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Isabel Ortega
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2026
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 05/18/2026
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The off-limits areas are the four bedrooms, one restroom, the den, the laundry area and attached garage (LPA observed a child safety knob). The area of isolation takes in the den which was inspected and is located by the entrance of the main home.

According to licensee she provides children enrolled with breakfast, lunch, and afternoon snack.

The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The knives are kept in a drawer (child safety locked) and far back on the kitchen counter. The chemicals are kept locked under the kitchen sink locked with a child safety latch. Medication is kept in an off limits bedroom.

The First Aid kit is complete. The required fire extinguisher (2A10BC) is reading in green (purchased within a year 4/27/20265). Smoke and carbon monoxide detectors are in operating condition., Fire and disaster drills are conducted every six months, last drill conducted and documented on 5/15/2026 at 10:30 a.m.

Licensees provided certificate of completion Pediatric First Aid and CPR training dated 9/04/2024. Pediatric First Aid and CPR does not expire until September 2026.

Childcare Provider Mandated Reporter training – General, Childcare Provider and Exam are required to be renewed every two-years. Licensee provided Child Care Provider Mandated certificate dated 09/10/2024.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Isabel Ortega
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 05/18/2026
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Licensee had all the required posted documents: Facility License (LIC 203, Notice of
Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148).

The licensee and staff maintain proof of immunization against pertussis (TDAP), measles
(MMR), Tuberculous (TB) and influenza.

The licensee is aware all adults living in or having access to the home are required to
have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please inform your Analyst of any person who will be visiting regularly or for longer than one week.

The Licensee was reminded to report Unusual Incidents. 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. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. Licensee was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Isabel Ortega
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
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: CHURCHILL FAMILY CHILD CARE
FACILITY NUMBER: 367700469
VISIT DATE: 05/18/2026
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Licensee is reminded with a capacity increase she must have a qualified assistant present whenever more than 8 children are present in care. Licensee was provided with a
capacity and ratio handout pertaining to large Family Child Care Homes and the various
age groups that can be under care at one given time.

Licensee has met Title 22 regulations; Fire clearance was granted 04/27/2026, therefore,
a Large Family Childcare Home License with a capacity of 14 children will be requested
from the department.

An exit interview was conducted, and a copy of this report, appeal and notice of site visit
was provided to Licensee on this day. All Licensing reports are recommended to be kept
on file for a minimum of three years and available to the public.
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Isabel Ortega
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC809 (FAS) - (06/04)
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