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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750049
Report Date: 04/11/2025
Date Signed: 04/11/2025 05:51:55 PM

Document Has Been Signed on 04/11/2025 05:51 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:OAK TREE D STREETFACILITY NUMBER:
367750049
ADMINISTRATOR/
DIRECTOR:		MELISSA DAVISFACILITY TYPE:
850
ADDRESS:1900 D STREETTELEPHONE:
(909) 882-6979
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: DATE:
04/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Facility Representative Josephine Hernandez TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On April 11, 2025, Licensing Program Analyst (LPA) Zirbes conducted a case management deficiencies inspection to address additional information obtained. LPA met with facility representative, Josephine Hernandez. Present during today's inspection were 16 preschool age children and three toddler age children.

The Department discovered through confidential interviews that teachers are required ensure the classrooms are clean and sanitary. Interviews with staff confirmed staff mop, sweep and preform housekeeping duties when children are under their care and supervision. On January 23, 2025, at approximately 07:00am, LPA Zirbes and Cha observed staff 1 (S1) supervising child 1 (C1) in a preschool classroom. LPAs observed S1 sweeping the classroom floors while C1 was engaged in free play activities. S1 confirmed it is common for the teachers to clean when the ratios are lower in the morning and in the evening. Based on confidential interviews and LPA observations, staff are performing housekeeping duties rather than engaging in the care and supervision of the children in care. Therefore, a Type B citation for regulation 101216.3 (g) Teacher-Child Ratio is being issued as this was a potential risk to the children in care. Refer to LIC 809D.


Notice of Site Visit was given and must remain posted for 30 days. An exit interview was conducted with facility representative Josephine Hernandez. Appeal rights and a copy of the report were provided to facility representative Josephine Hernandez.

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2025
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.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/11/2025 05:51 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 04/11/2025 at 04:02 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: OAK TREE D STREET
FACILITY NUMBER: 367750049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
101216.3(g)

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101216.3 (g) Teacher-Child Ratio: A teacher shall not be required to perform housekeeping or maintenance duties that prevent him/her from performing duties related to providing care and supervision to children. This requirement was not met as evidenced by: Based on interviews and
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Per facility representative the staff completed a training on January 29, 2025 regarding teacher interactions. and an active supervision January 16, 2025. A copy of the training was received.
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 observations, teachers are responsible for cleanliness of the classroom. In order to complete this task, the teachers are performing housekeeping duties while providing care and supervision. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lady King
NAME OF LICENSING PROGRAM MANAGER:
Kendal Zirbes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2025


LIC809 (FAS) - (06/04)
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