367750050-5-20-2025-12-CC-KZIS-DGUV4G-20250520160619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 367750050
Report Date: 05/20/2025
Date Signed: 05/20/2025 04:06:40 PM

Document Has Been Signed on 05/20/2025 04:06 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 STREET		FACILITY NUMBER:	367750050
ADMINISTRATOR/ DIRECTOR:	MELISSA DAVIS		FACILITY TYPE:	830
ADDRESS:	1900 D STREET		TELEPHONE:	(909) 882-6979
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92405
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 9	CENSUS:	DATE:	05/20/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Facility Representative Meliss Davis and Josephine Hernandez		TIME VISIT/ INSPECTION COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 20, 2025, Licensing Program Analysts (LPA) Zirbes and Cha met with facility representative Melissa Davis and Josephine Hernandez 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 May 15, 2025. The unusual incident report was regarding an injury child 1 (C1) received at the Center. Upon arrival today, there were nine infants in care with four teachers, and additional supportive /administrative staff in site. During this inspection, interviews were with conducted staff 1 (S1), staff 2 (S2) and staff 3 (S3). LPA attempted to complete confidential child interviews, however due to the ages of the children in the classroom they were unable to communicate details about C1s injury. In addition, LPA reviewed staff and child files. Furthermore, LPAs completed a safety inspection of the Center. The information received from the UIR reported that on May 15, 2025, at approximately 09:19am, C1 slipped by the sand box from sand and hit the nose area. C1 was provided with first aide and C1s authorized representative was contacted. Based on LPAs record review and interviews, at the time of the incident, S1, and S2 were in the outdoor activity space at the time of the incident. Interviewees reported S1 and S2 were supervising five infants at the time of the incident therefore ratios were being met. Interviewees provided conflicting information regarding the activity C1 was engaged in prior to slipping and if C1 nose hit cement or the rubber surfacing. All interviews reported C1 slipped in the dirt/sand mixture surrounding the tree in the outdoor activity space. Report continued on page two

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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

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)

Page: 2 of 3

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: 05/20/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Report continued from page two

LPAs toured the outdoor activity space; the area was free of hazards at the time of this inspection. LPAs observed sand/dirt was on the cement walkway in the outdoor activity space and advised the Center to sweep the area prior to each classroom engaging in outdoor play. LPAs advised the Center to keep a broom in the outdoor space that is inaccessible to the children but accessible to the teachers.

Based confidential interviews and record review at this time, the incident does not appear to have been the result of a violation of the Title 22 regulations.

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

NAME OF LICENSING PROGRAM MANAGER: Lady King
NAME OF LICENSING PROGRAM ANALYST: Kendal Zirbes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3