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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700137
Report Date: 02/22/2023
Date Signed: 11/06/2023 09:46:10 AM

Document Has Been Signed on 11/06/2023 09:46 AM - 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:WILLIAMS FAMILY CHILD CAREFACILITY NUMBER:
367700137
ADMINISTRATOR:KIESIA WILLIAMSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 662-3819
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kiesia WilliamsTIME COMPLETED:
03:45 PM
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On 2/22/2023, Licensing Program Analyst (LPA’s) Kris Diaz and Carol Heath conducted an unannounced Required 1-Year inspection at the Williams Family Child Care Home. Upon arrival, the LPA's met with the licensee, Kiesia Williams, who guided the LPA's on a tour of the facility. Individuals that reside in the home include 1 adult (licensee) and 2 children (ages: 12 and 9).
Licensee's assistant, Kizziea Schenk was present during this inspection, 11 childcare children were present. Per the licensee, the hours of operation are Monday through Friday, 6:00 a.m. to 6:00 p.m. Incidental Medical Services (IMS) were discussed. Per the licensee, she does not have children who need IMS at this time.

The home is set up as follows:
This is a one-story home with 3 bedrooms, 2 bathrooms, kitchen, a living room, a family room, and a garage. The home was inspected for safety, comfort, cleanliness, central air, and heat and ventilation. The licensee uses cell phone as home phone. All windows have screens and are free of cracks, bugs, and debris. There is no pool, spa, or other bodies of water on the premises.

Ø Main Area: Main care is provided in the living room. The children use bathroom down the hallway. Children have access to the bathroom down the hallway. There are games and books on the premises of this facility.
· Living Room: In the living room, which is the designated daycare, LPA's observed age-appropriate toys and furniture for the children. There are games and books on the premises of this facility. There are mats on the floor with educational/learning activities. The carpets were observed to be in good condition. There is a TV that plays educational videos and age-appropriate movies for the children. There are cubbies used for storage of children’s items and toys. LPA reminded licensee that cubbies cabinets need to be anchored to the wall.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137
VISIT DATE: 02/22/2023
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· Children's bathroom: Children will use the bathroom down the hallway. The bathroom was clean and in good repair. The toilet was inspected sink/toilet is in operable condition. The toilet and faucets are clean, safe, and operable. All cabinets are made inaccessible to children with child safety latches The drawers were accessible to children. LPA reminded licensee that drawers need safety latch to make inaccessible to children. The bathroom was observed to be free and clear of hazardous items. Licensee keeps medications locked in master bedroom which is inaccessible to children.
Ø Off-limit: Off-limit areas bedroom and bathroom #1, bedroom #2 and master bedroom.
· Bedroom #1: Bedroom #1 is near the front entrance and located near the main daycare area. This is an off-limits area that is accessible to the children. LPA reminded licensee that bedroom door needs a safety knob to make inaccessible to children.
· Office/Bedroom #2: Bedroom #2 is accessible to children. LPA reminded licensee that bedroom needs a locking mechanism to make the room inaccessible to children.

· Master Bedroom: Licensee’s bedroom is inaccessible to children. Licensee informed that medications are kept in bathroom.

· Kitchen/Dining Room: The kitchen was inspected to ensure hazardous and dangerous items were inaccessible to children. All sharp utensils, poisons, and medications are unavailable to children in the kitchen. Sharp knives are kept in an upper cabinet.


· Backyard: Licensee signed declaration making the backyard inaccessible to children.
Ø Others:
· AC/Heating Unit was observed. AC/Heating Unit is located on the patio in the backyard of the home and is inaccessible to children as indicated in signed declaration.
· Bodies of water: Per the licensee, there are no bodies of water in the home.
· Electrical outlets: All unused electrical outlets are made inaccessible to children.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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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: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137
VISIT DATE: 02/22/2023
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· The licensee has posted as required the Facility License, Emergency Disaster Plan, Earthquake Preparedness, and Parents' Rights Poster.
· Food: The licensee is enrolled in Food program. The licensee will provide breakfast, am snack, lunch, pm snack and dinner. Per licensee no food is provided from outside. LPA reminded licensee that if food is provided it should be labeled and properly stored.
· Fire extinguisher (2A10BC): LPA did observe licensee purchase a required fire extinguisher (2A10BC). It meets standards established by the State Fire Marshall.
· Fireplace: The fireplace was observed in the family room which is an off-limits area. LPA reminded licensee that fireplace should contain safety latch.
· Hanging window blind cords: LPA reminded licensee that blind cords should be tied to make inaccessible to children.
· Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing 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)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. The licensee will not be providing IMS to the children at this time.
· Isolation area (Illness): Per the licensee, if the child shows signs of illness, they will be separated from other children and stay in main daycare area to maintain ratio compliance.
· Medications and cleaning solutions: Detergents/cleaning compounds are in kitchen and inaccessible to children. LPA reminded licensee that safety latch should be on cabinets containing poisons and cleaning solutions. Medications are in the off-limits bedroom.
· Napping: Children will nap in main daycare area with adult supervision. LPA observed 10 mats in the main daycare area near the front entrance. LPA observed two play pens.
· Overnight Care: According to the licensee does not provide overnight care.
· Pets: Per licensee there are no pets in the home.
· Phone service: There is a working cell phone.
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137
VISIT DATE: 02/22/2023
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· The First Aid kit is located in the front closet. LPA observed an empty kit containing no first-aid supplies. LPA reminded licensee that she needs a fully supplied first-aid kit and first-aid manual that is inaccessible to children and contains no medications. LPA observed licensee's assistant purchased first-aid kit containing first-aid manual during the visit.
· Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license, valid vehicle insurance, and vehicle registration.
· Weapons or Firearms: Per the licensee, there are no firearms at the facility at this time. LPA did not observe any firearms.
Ø Documentation:
· Child files: LPA reviewed 8 children's records. The records are incomplete and missing forms. LPA provided licensee with LIC311D and packet of all required forms (as applicable) and reminded licensee that files should be maintained at all times. LPA reminded licensee that files of children no longer enrolled should be maintained for 3 years.
· CPR/First Aid: LPA observed licensee does not have current Pediatric CPR and First- Aid Training including1 hour of nutrition training and (8) hours of Preventive Health and Safety Training.. Certifications expired 3/16/2021.
· Criminal Record: Per Guardian, all adults in this facility have obtained a criminal record clearance. This was also observed from the guardian clearances. Assistant Jasmene Parker is not currently caring for children in the childcare facilty.
· Facility fees: Per Licensing Information System, annual facility fees were current.
· Fire Drill and Disaster Drill: Per the licensee, fire, and disaster drills are conducted; the last drill was documented and performed on 12/6/2019. LPA reminded licensee that fire and disaster drills should be conducted every 6 months and documentation should be logged and accessible to parents.
· Immunization: The licensee has the required immunizations (MMR and DTaP). The licensee and her assistant provided a written statement declining the influenza vaccination.
· Infant Sleeping Plan (LIC 9227) and Sleeping Log: LPA observed there is 1 infant enrolled in the facility. The child is over 12 mos; therefore, the LIC 9227 is not required. LPA informed licensee that sleep log is required to be maintained and kept in child’s file. LPA shared the Safe Sleeping Regulation with the licensee.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137
VISIT DATE: 02/22/2023
NARRATIVE
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· Mandated Reporter Training: The licensee has not renewed the online mandated reporter training at www.mandatedreporterca.com. LPA advised licensee that training is required and must be renewed every 2 years.
· Staff Personnel File: LPA observed 1 staff information. The file did not contain all required licensing documents. LPA reminded licensee that staff files should be maintained and accessible to licensing staff upon request.
· Staffing Ratio and Capacity: This is a large family childcare facility. During the inspection, LPA observed 11 children (1 school-age and 10 preschool). Licensee was in compliance with 1 assistant in the facility.

Ø The following information was discussed with the licensee:
ü Mandatory Forms for the children's files and provider's files.
ü Requirements for fire drills, earthquake drills, and documentation for both.
ü The licensee is reminded that 100% supervision is required for children at all times.
ü Capacity requirements, Roster requirements, Posting requirements, and Documentation requirements for disaster drills (fire and earthquake). Safe Sleep Awareness was discussed and PIN 20-24-CCP was provided to the licensee. The role and responsibilities of being a mandated reporter were reviewed.
ü Licensee was made aware that it is their responsibility to know the regulations and anyone who assists in providing care. Licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility's phone number; if the phone number is changed, licensing must be notified.
ü Licensee was advised of the requirement to report unusual incidents and injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
ü The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
ü Criminal Record Statement: Licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption or transfer their existing support or exemption prior to the initial presence in a licensed Family Child Care Home. 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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
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 CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137
VISIT DATE: 02/22/2023
NARRATIVE
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ü Safe Sleep: LPA discussed the safe sleep regulations with the licensee [or 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 the licensee [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.
ü A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety code sections 1596.848(b) and (c).
ü Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
ü Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
ü The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban).
ü State law prohibits baby walkers, bouncy seats, exersaucer, and other items that fall into that category.
ü Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations.
n Our Quarterly updates come out every 3 months. They are also now in Spanish. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: [email protected]

ü The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 a.m. - 5:00 p.m. Deficiencies cited: (See LIC 809D).

The following Type A/B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and Health & Safety codes. An exit interview was conducted, and the report was reviewed with the licensee Kiesia Williams.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kristina Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 6 of 37
Document Has Been Signed on 11/06/2023 09:46 AM - It Cannot Be Edited


Created By: Kristina Diaz On 02/22/2023 at 02:12 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: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2023
Plan of Correction
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LPA provided licensee with disaster plan and licensee posted.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA did not observe current mandated reporter training from licensee and staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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LIcensee will email certificate to LPA
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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 7 of 37
Document Has Been Signed on 11/06/2023 09:46 AM - It Cannot Be Edited


Created By: Kristina Diaz On 02/22/2023 at 02:12 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: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe immunization records for staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2023
Plan of Correction
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Licensee will email proof of immunizations to LPA
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe records od completion of required CPR/First-aid training for licensee and at least one staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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2
3
4
Licensee will provide proof of registration to LPA.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 8 of 37
Document Has Been Signed on 11/06/2023 09:46 AM - It Cannot Be Edited


Created By: Kristina Diaz On 02/22/2023 at 02:12 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: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe complete records for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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LIcensee will provide proof of correction to LPA via email.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe immunizations for all children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2023
Plan of Correction
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2
3
4
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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
Page: 9 of 37
Document Has Been Signed on 11/06/2023 09:46 AM - It Cannot Be Edited


Created By: Kristina Diaz On 02/22/2023 at 02:12 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: WILLIAMS FAMILY CHILD CARE
FACILITY NUMBER: 367700137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA did not observe completed facility roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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2
3
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Licensee will email a copy of completed and updated roster to LPA.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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4
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:Claretta Yates
LICENSING EVALUATOR NAME:Kristina Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
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