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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750050
Report Date: 11/03/2023
Date Signed: 11/03/2023 04:18:57 PM

Document Has Been Signed on 11/03/2023 04:18 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:
367750050
ADMINISTRATOR:MELISSA DAVISFACILITY TYPE:
830
ADDRESS:1900 D STREETTELEPHONE:
(909) 882-6979
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Facility Representative Juanita GutierrezTIME COMPLETED:
02:30 PM
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On November 3, 2023 at 1:31 pm Licensing Program Analyst (LPA) Zirbes met with facility representative Juanita Gutierrez to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted to the Department on October 25, 2023. The unusual incident report was regarding a potential personal rights incident involving child 1 (C1).

During this inspection, interviews were conducted with staff. Child interviews were not completed as the children involved in the incident are under the age of two. In addition, LPA reviewed staff and child files. Furthermore, LPA also completed a safety inspection of the Center.

Additional time is required to investigate this incident.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with facility representative Juanita Gutierez.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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