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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750017
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:54:37 PM

Document Has Been Signed on 10/30/2023 03:54 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:CHAMPIONS@RALPH BAKER 21ST CENTURY LEARNING CENTERFACILITY NUMBER:
367750017
ADMINISTRATOR:MURRAY, KEITHFACILITY TYPE:
840
ADDRESS:15456 EL EVADO RDTELEPHONE:
(760) 338-9359
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 40DATE:
10/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Valeria Villalobos, Site SupervisorTIME COMPLETED:
04:00 PM
NARRATIVE
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On October 30, 2023 Licensing Program (LPA) Calloway conducted an Annual Continuation inspection at the above facility. LPA met with Site Supervisor (S1) who provided access. LPA arrived and observed no kids care and four (4) staff members. During the inspection, forty kids (40) arrived within twenty minutes.

Per Title 22 Regulations, there were deficiencies cited during this inspection. There was one (1) Type A deficiency for 101170(e)(2) - Criminal Record Clearance and two (2) Type B deficiencies 1596.8662 (D)(4)(b)(1) - Availability of Information, and 101212(b) for Reporting Requirements. See 809 D pages.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.
An exit interview was conducted, a copy of this report was read, and a Notice of Site Visit and Appeal Rights were provided to Valerie Villalobos, the facility. A Notice of Site Visit must be posted for thirty (30) consecutive days, failure to comply with posting will result in $100 civil penalty.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/30/2023 03:54 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/30/2023 at 02:59 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: CHAMPIONS@RALPH BAKER 21ST CENTURY LEARNING CENTER
FACILITY NUMBER: 367750017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, record review the licensee did not comply with the section cited above in four out of four staff S1-S4 did not have criminal clearance associated or transferred to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Adminstrator or Site Supervisor shall provide proof to Licensing by POC date of 10/31/23.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/30/2023 03:54 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 10/30/2023 at 03:04 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: CHAMPIONS@RALPH BAKER 21ST CENTURY LEARNING CENTER
FACILITY NUMBER: 367750017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, record review, the licensee did not comply with the section cited above in four out of four staff did not have the Mandated Reporter Training in their staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Site Director will provide proof to Licensing by requested POC date of 10/30/23.
Type B
Section Cited
CCR
101212(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on interview, record review, the licensee did not comply with the section cited above in Regional Adminstrator/Office did not provide proof of new Site Director within 10 Days of appointing the new Center Director which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Adminstration/ Regional Manager will provide Proof of LIC 308 Director Qualifications and to Licensing by requested POC date of 12/1/23
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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