Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492944
Report Date: 05/03/2017
Date Signed 05/03/2017 05:19:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:KIDS TOWN CHILDCARE CENTER, LLCFACILITY NUMBER:
197492944
ADMINISTRATOR:KIMBERLY MCKINNEYFACILITY TYPE:
850
ADDRESS:1825 WEST AVENUE J, SUITE 123TELEPHONE:
(661) 951-2070
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:36CENSUS: 13DATE:
05/03/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Director, Ms. KimTIME COMPLETED:
05:31 PM
NARRATIVE
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Licensing Program Analyst (LPA's) Maddox and Yates met with Director, Ms. Kim today for the purpose of investigating and Unusual Incident involving child #1. From information gathered, children were in the bathroom unattended washing their hands and splashing water. Child #1 slipped and fell from the water on the floor causing him to hit the rear part of his head. Child was taken to the Dr as a precautionary measure.
During this investigation, Director allowed LPA's to view the video from the date the incident occurred. LPA's observed a little girl in the bathroom first (this is a jack-n-jill bathroom that has 4 toilets and 4 sinks), and after approximately a few seconds, child #1 entered the bathroom. The video revealed the little girl in the bathroom for at least 2.5 minutes washing her hands and playing in the water. When child #1 entered the bathroom, he began washing his hands but within seconds, he and the little girl started engaging in water play. The little girl continuously splashed water on child #1 and he splashed her with water as well. Soon, child #1 left out of the bathroom and soon he returned and resumed splashing water on the little girl. Within a few seconds, child #1 fell to the ground.

LPA interviewed child #1 and the Lead Teacher whom was present when the incident occurred. Teacher stated she was watching the children from outside the bathroom area and also supervising children within the classroom. There was another teacher observed in the classroom at the time of the incident (this teacher was not near the bathroom area). LPA's attempted to question Child #1, he was very apprehensive and unable to give details or disclose what happened.
SUPERVISOR'S NAME: Burnett MageeTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2017
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: KIDS TOWN CHILDCARE CENTER, LLC
FACILITY NUMBER: 197492944
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2017
Section Cited
101212(d)
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101212(d) Reporting Requirements. A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified. Staff failed to call in this Unusual Incident within 24 hours as required.
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Director shall ensure all reportable incidents are called in within 24 hours and followed by a written within 7 days of the incident.
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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: Burnett MageeTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: KIDS TOWN CHILDCARE CENTER, LLC
FACILITY NUMBER: 197492944
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2017
Section Cited
101229
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time. Children were left unattended in the bathroom splashing water which led to child #1 slipping and falling hitting his head. Child #1 was taken to the Dr as a precautionary measure, diagnosed with a contusion.
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Director shall submit a written plan by the POC due date (5/4/17) which should entail how they will provide adequate supervision to children in care at all times in an effort to prevent any reoccurring injuries.
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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: Burnett MageeTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: KIDS TOWN CHILDCARE CENTER, LLC
FACILITY NUMBER: 197492944
VISIT DATE: 05/03/2017
NARRATIVE
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After interviews and viewing of the video, it appears as though there was Lack of Supervision . LPA's did not observe any teachers supervising the children while they were in the bathroom (approximately 3 minutes from time and date stamp on video). Citation issued today for Lack of Care and Supervision. A Type A citation was issued as a result of this Unusual Incident. Child #1 was taken to the Dr. by parent and diagnosed with a contusion (bruise) on the rear of his head. Staff failed to call in the report by the next business day as required.

Each report documenting a Type A citation (Imminent threat to children) shall remain posted for 30 days along with the Notice of Site Visit. Family child care homes shall post during hours of operation. Failure to meet the posting requirements shall result in an immediate $100.00 civil penalty. In addition, parents of currently enrolled children and any newly enrolled child for the following 12 months shall receive a copy of the report (documenting a Type A citation) and sign the LIC 9224 acknowledging receipt. Civil Penalty assessments will be assessed if all above requirements are not adhered to.


Exit interview conducted, Staff is advised to provide close supervision to children at all times. Appeal Rights were printed and distributed to Director during this investigation.
SUPERVISOR'S NAME: Burnett MageeTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2017
LIC809 (FAS) - (06/04)
Page: 4 of 4