197416405-9-6-2023-12-CC-AALH-CVEPHM-20230906112011

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197416405
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:20:39 AM

Document Has Been Signed on 09/06/2023 11:20 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:	KOWALCZYK FAMILY CHILD CARE		FACILITY NUMBER:	197416405
ADMINISTRATOR:	KOWALCZYK, CYNTHIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 456-5166
CITY:	CANYON COUNTRY	STATE: CA	ZIP CODE:	91351
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee Cynthia Kowalczyk		TIME COMPLETED:	12:00 PM

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On 09/06/2023 Licensing Program Analyst (LPA) Alemoh, met with licensee, Cynthia Krowalczyk who guided analyst on a tour of the facility for the One Year Required inspection. This is one story home with 4 bedrooms, 2 bathrooms. Upon arrival LPA observed 4 children in care and 2 adults (licensee, and an aid) caring for them. Family members residing in the home include 1 adult (licensee). Facility hours of operation are Monday - Sunday for 24 hour, per licensee overnight is provided upon parents request. Incidental Medical Services (IMS) policy was discussed.

There is no bodies of water on the premises.

Physical Plant: Main care is provided in the play room. LPA observed age appropriate toys and play equipment. There is a room for the older children to do homework, and play. LPA observed the big kids room to be clean and orderly. Desk and play equipment were observed. Per licensee older children use the room for study and homework time. The children use the bathroom located in the hallway to the left. The off-limits areas are all 1 bedroom, stoarage/ guest room, and backyard #2. Laundry room and garage are also off limits and are kept locked during business hours. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds which are kept in the underneath the kitchen sink, medicines are kept in the off-limits area and

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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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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: KOWALCZYK FAMILY CHILD CARE	FACILITY NUMBER: 197416405
	VISIT DATE: 09/06/2023

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hazardous items (sharp knives are kept in the kitchen in the upper cabinet high enough that they are inaccessible to children).

Safe and age appropriate toys, play equipment and materials were observed. The smoke detector, carbon monoxide detector and Fire Extinguisher (2A10BC) are all in operable condition. Electrical outlets are inaccessible. No recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the dinning room. Per Licensee, there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).

Fire/Disaster drills are maintained current. Last fire disaster drill was completed on 08/23/23.

Bathroom: LPA observed the toilet and faucet are clean and operable. The shower/tub area is free of prohibited items such shampoos, body wash and razors. LPA observed the cabinets to be locked with a safety latch containing body wash and shampoos.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are underneath the kitchen sink w/ a safety latch making it inaccessible to children. All kitchen cabinets are have safety latches. Breakfast, lunch, snacks and dinner are provided. Licensee stated she currently does not have a food program. Naps are provided on mats in the playroom.

Outdoor: The front yard is off limits. There are two backyards. Backyard #1 is off-limits. The backyard is completely fenced in with a tall white fence. Backyard #2 is separated by a gate. There are two cats in the premises and they are de-clawed. Per licensee, cats do not come in contact when children are present.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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: KOWALCZYK FAMILY CHILD CARE	FACILITY NUMBER: 197416405
	VISIT DATE: 09/06/2023

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LPA observed age appropriate toys, well secured and safe for children. Turf was observed around the play yard area. The turf field has rubber underneath making it safe for soft landings for the day care children. Play structures were observed to be safe and sturdy, there is a sand box that the play structures sit on. LPA observed the BBQ pit in backyard #1 to be off-limits and covered making it inaccessible to children.

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expires 04/29/24. Mandated Reporter expires on 04/28/24. LPA reminded licensee; mandated reporter training must be completed every 2 years.

Documents Provided and or Discussed: Children's records, Safe Sleep PIN 20-24-CCP and Individual Sleeping Plan (LIC9227). Licensee currently does not have child care insurance.

Licensee Cynthia 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 clearance or exemption, prior to 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.

LPA discussed the safe sleep regulations with licensee Cynthia and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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: KOWALCZYK FAMILY CHILD CARE	FACILITY NUMBER: 197416405
	VISIT DATE: 09/06/2023

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	An exit interview was conducted, a copy of this report was reviewed and provided to licensee along with the appeal rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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