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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750079
Report Date: 01/28/2025
Date Signed: 01/28/2025 02:02:11 PM

Document Has Been Signed on 01/28/2025 02:02 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:APPLE VALLEY CHRISTIAN ACADEMYFACILITY NUMBER:
367750079
ADMINISTRATOR/
DIRECTOR:		TAYLOR ALLENFACILITY TYPE:
860
ADDRESS:22434 NISQUALLY RD.TELEPHONE:
(760) 475-0184
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 1DATE:
01/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Chloe Gold TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On January 28th 2025, Licensing Program Analyst (LPA's) Braddock and Cha met with Director. The purpose of the inspection was to conduct an unannounced case management inspection at the licensed facility. LPA disclosed the purpose of the inspection to the Licensee. When LPA's arrived to the facility, there were 3 staff members and 1child in care

LPA's and Licensee completed a safety tour of the facility. During the inspection LPA observed cleaning solutions accessible to children in care. Director immediately removed the solution and placed it in a locked cabinet once LPA's informed her about the safety risk.

Based on LPAs observations 1 citation were issued under 101238 (g)(1)

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Licensee.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Sherell Braddock
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 2
Document Has Been Signed on 01/28/2025 02:02 PM - It Cannot Be Edited


Created By: Sherell Braddock On 01/28/2025 at 01:46 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: APPLE VALLEY CHRISTIAN ACADEMY
FACILITY NUMBER: 367750079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2025
Section Cited
HSC
101238(g)(1)

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101238 Buildings and Grounds (g)Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.(1) Storage areas for poisons shall be locked.
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Director removed cleaning solutions and store them in a locked cabinet
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This requirement is not met as evidenced Based on observations cleaning solutions were left accessible to children which poses an Potential Health and Safety risk to children 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.
SUPERVISOR'S NAME:Lady King
LICENSING EVALUATOR NAME:Sherell Braddock
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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