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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750050
Report Date: 04/29/2025
Date Signed: 04/29/2025 03:37:58 PM

Document Has Been Signed on 04/29/2025 03:37 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:OAK TREE D STREETFACILITY NUMBER:
367750050
ADMINISTRATOR/
DIRECTOR:		MELISSA DAVISFACILITY TYPE:
830
ADDRESS:1900 D STREETTELEPHONE:
(909) 882-6979
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
04/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Facility Representative Melissa Davis TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On April 29, 2025 at approximately 9:50am, Licensing Program Analyst (LPA) Zirbes and Cha met with facility representative Melissa Davis. The purpose of the visit was to conduct an unannounced Annual/Random inspection of the facility. LPA disclosed the purpose of the inspection to the Facility Representative Melissa Davis. LPA toured and inspected the two Infant classrooms. In Infant room #1 (infants 12 months and younger), LPA observed one teacher and one aide providing care and supervision to four infants at time of inspection. In Infant room #2 (infants 12 months and older), LPA observed one teacher and one floater aide providing care and supervision to five infants. Per facility representative, one additional aide in Infant room #2 was taking a break at time of inspection. The facility is approved for a toddler option in Toddler room #3, which is associated with the preschool license. The current days and hours of operation are Mondays through Fridays; 6:30am-6:00pm.

Indoor/Children's Area: The facility was inspected for safety, comfort, cleanliness, and good repair. There are two separate Infant rooms (Infant room #1 and Infant room #2). The indoor space for infants is physically separate from space used by children in the preschool program. Infant classroom #1 is equipped with age-appropriate furniture. equipment, changing table, and in good repair. LPA did not observe sharp points or edges. There is one hand washing sink and changing table.
LPA observed the feeding table to be in good repair. LPA observed Child #1 (C1) seated at feeding table being served lunch by one staff member. All seats on the feeding table did not include a safety belt. LPA observed C1 sitting at feeding table with no safety belt. Per facility representative, feeding table never included attached seat belts. User manual unavailable due to feeding table being purchased by neighboring church staff. A Technical Advisory issued. LPA advised facility representative to install seatbelts on feeding table seats for additional safety for children. Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Hanna Cha
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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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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: OAK TREE D STREET
FACILITY NUMBER: 367750050
VISIT DATE: 04/29/2025
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Infant classroom #2 is equipped with age-appropriate furniture. equipment, changing table, and feeding tables in good repair. LPAs did not observe sharp points or edges. There is one hand washing sink and changing table. At the time of inspection, the facility was in compliance with the staff/infant ratio and was not exceeding the approved capacity for the facility. LPA observed age-appropriate toys and equipment in good repair. Each infant has container labeled with their name for the storage of personal items.
LPAs observed the cleaning compounds were stored on in lower cabinets made inaccessible by a child safety lock. The cleaning supplies are stored separately from food. The infant center does not have a fire place. The building has central heating and air conditioning. The room temperature was comfortable at the time of this inspection. LPA observed carbon monoxide and smoke detectors in operable condition. LPA observed fire extinguishers. There is a working telephone on the premises. There is an isolation room for ill children.

Napping: LPAs observed cribs and cots. Each crib was assigned to a specific child and labeled with the child’s name. LPAs observed the crib mattresses were made of a cleanable vinyl material and were in good repair. Crib mats were covered with fitted sheets and was free of items. Per Infant staff, crib mats and cots are wiped and disinfected daily. Soiled sheets are washed daily.
Per LPA observation, feeding table was located inside the sleeping area for infants. LPA observed Child #1 (C1) seated at the table being served lunch by one staff member. There were two children sleeping in separate cribs directly adjacent to C1. LPA observed no barrier between sleeping and eating area. However, there was no auditory disturbance from C1 that prevented two children in cribs from sleeping. At time of inspection, two children in cribs were sleeping. A Technical Violation issued.

Restrooms: At time of inspection, all infants are in diapers. There is a restroom located between Infant room #1 and Infant room #2 that is currently not being used by children. A diaper changing area was located in both Infant room #1 and Infant room #2 and observed to be clean and sanitary.

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NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Hanna Cha
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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: OAK TREE D STREET
FACILITY NUMBER: 367750050
VISIT DATE: 04/29/2025
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Outdoor: Outdoor play equipment was inspected for health, safety, good repair and age appropriateness. The outdoor play area is enclosed by a fence. LPA observed age-appropriate equipment, toys, and shady areas.
Pools/Spa/Bodies of Water: Per LPA observation and facility representative, there are no pools, spas, or bodies of water on the premises.

Other: LPA observed electrical outlets are inaccessible. Window cords were inaccessible to children. Per staff member, toys and equipment are wiped and disinfected daily. Per facility representative, no smoking is allowed on the premises. LPAs did not observe baby walkers or other prohibited play equipment on the premises. Per facility representative, there are no firearms/weapons stored on premises. First Aid Kit included supplies readily available and made inaccessible to children. Per recorded documentation, Fire/Earthquake drills last completed on 4/11/2025. Lead testing completed on 8/29/2024.

File Review:


LPA reviewed five child files which included all required documentation, including quarterly Needs and Services plans.

Postings:


LPA observed required postings as follows: Facility License, Personal Rights (LIC613A), Parent’s Rights Poster, Passenger Car Seat Law (PUB 269), and Emergency Disaster Plan.
To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Hanna Cha
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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: OAK TREE D STREET
FACILITY NUMBER: 367750050
VISIT DATE: 04/29/2025
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Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Hanna Cha
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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: OAK TREE D STREET
FACILITY NUMBER: 367750050
VISIT DATE: 04/29/2025
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Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Due to time constraints, LPA was unable to complete inspection. LPA will return to facility at a future date to complete staff files review.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Melissa Davis along with Appeal Rights.

Last Page

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Hanna Cha
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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