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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750050
Report Date: 11/17/2023
Date Signed: 11/17/2023 04:57:19 PM

Document Has Been Signed on 11/17/2023 04:57 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: 8DATE:
11/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Facility Representative Juanita GutierrezTIME COMPLETED:
05:05 PM
NARRATIVE
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On November 17, 2023, at 10:01a.m. Licensing Program Analyst (LPA) Kendal Zirbes met with Facility Representative Juanita Gutierrez. The purpose of the inspection was to conduct the annual continuation inspection at the licensed facility. LPA disclosed the purpose of the inspection to the facility representative. Present during today’s inspection were 8 infant age children, one teacher (staff 1 (S1)), and one aide (staff 2 (S2).

Food Service: The facility currently prepares food off site and delivers the food to this Center. If required the food is warmed up utilizing a shared kitchen with the Church. During the inspection, LPA completed a tour of the kitchen area. The area as clean and sanitary. The facility provides breakfast, two snacks and lunch for the children over 12 months. For children under 12 months, the family provides breast milk/formula, and baby food. LPA observed the food brought from the children's home was labeled and dated. Per Administrator zero sinks are utilized for food preparation. Bottled water is utilized for the bottles and food preparation.
Posting Requirements: Center has required postings posted (license, PUB 393, car seat law information). LPA advised the Center to update the Palmdale Regional Office address on the PUB 393.

Files: During the inspection LPA reviewed five child files. Based on LPA review and the conversation with the Administrator the needs and service plans were being updated every 6 months instead of quarterly. A type B citation was issued. In addition, two of five child files reviewed were missing the medical assessment. The children have been enrolled for over 30 days. A type B citation was issued. Furthermore LPA reviewed the 15 minute safe sleep checks.. Per LPA review and conversation with the Administrator the 15 minute checks were being completed however were not being documented for the children over 12 months of age. A Type B citation was issued.
Report continued on page two
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/17/2023 04:57 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 11/17/2023 at 03:18 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: 367750050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview , the licensee did not comply with the section cited above when the 15 minute checks were not being documented for the children over the age of one, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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Per Administrator, documentation of the 15 minute checks will start on Monday. A staff training will be completed regarding the documentation. A copy of the training will be submited to the Department.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two of five personnel files reviewed were missing a health screening. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Per Administrator, the staff will obtain the health screening and administration will review files to ensure all staff members have the required health screening.
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:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


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Document Has Been Signed on 11/17/2023 04:57 PM - It Cannot Be Edited


Created By: Kendal Zirbes On 11/17/2023 at 03:18 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: 367750050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.3(a)
Modifications to Infant Needs and Services Plan
(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above the needs and service plans were being updated every 6 months instead of quarterly, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Per Administrator, the needs and service plans will be updated every quarter. The Center will completed a checklist to ensure plans updated as required.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two of five child files reviewed were missing the medical assessment. The children have been enrolled for over 30 days. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Per Administrator, the medical assessment will be obtained and the administrator will complete a child file reviews to ensure completeness.
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:Lady King
LICENSING EVALUATOR NAME:Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


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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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OAK TREE D STREET
FACILITY NUMBER: 367750050
VISIT DATE: 11/17/2023
NARRATIVE
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Report continued from page one

File review continued: On 11.3.23, LPA observed oral pain relief medication and diaper rash spray relief in the infant classroom. Per conversation with the Administrator the non prescription medications had not been provided to the infants. Per LPA review the child files did not contain approval from the authorized representatives allowing the Center to administer the pain relief and diaper spray. Two technical advisory notices were issued to the Center regarding non prescription medication.

LPA reviewed five personnel records. Based on LPA reviewed two of five personnel files reviewed were missing a health screening. One Type B citation was issued.

Based on LPA observation and interview with the Administrator the facility has not completed the required Lead testing within 180 days of licensure. Per LPA observation there are zero drinking fountains within the indoor or outdoor licensed spaces of the infant Center. Per Administrator the sinks located in the shared church kitchen and the small kitchen area located near the infant classroom are not utilized for food preparation. Per Administrator, all sinks are used for hand washing only or for the washing of dishes/bottles. Bottled water is utilized for all children’s drinking and food preparation. LPA observed four bottles of one gallon bottled water within the kitchen. LPA did not observe the staff utilize the sinks for children’s drinking and food preparation. A technical violation was issued as the Center did not have their Lead testing completed as required, and did not submit a written statement attesting that the CCC has not used, and will
not use, any water outlets used for drinking water or food preparation. LPA provided the facility with guidance regarding the required Lead testing.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Report continued on page three
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
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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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: OAK TREE D STREET
FACILITY NUMBER: 367750050
VISIT DATE: 11/17/2023
NARRATIVE
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Report continued from page two

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative 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 facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Based on LPA observations, and record review, four type B citations were issued along with technical advisory notice.



A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Administrator Melissa Davis.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
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