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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502305
Report Date: 04/20/2022
Date Signed: 04/20/2022 05:39:58 PM


Document Has Been Signed on 04/20/2022 05:39 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:TRINITY LUTHERAN PRESCHOOL & DAY NURSERYFACILITY NUMBER:
191502305
ADMINISTRATOR:FRANCES COWARDFACILITY TYPE:
850
ADDRESS:11609 S. STUDEBAKER ROADTELEPHONE:
(562) 864-2319
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:64CENSUS: 27DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Debra TorresTIME COMPLETED:
05:50 PM
NARRATIVE
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On 4/20/22 Licensing Program Analyst (LPA) Jeanette Estrada conducted an unannounced required 1 year inspection. LPA met with Director Debbie Torres who guided analyst on a tour of the facility. This is a preschool program which consists of two classrooms. Facility operates from Monday through Friday 6:30AM to 6:00PM. There were 27 children present with 4 staff when LPA arrived.

All areas identified on the facility sketch were inspected. Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Children nap on cots in each classroom. Children bring their own bedding and take it home each week to maintain clean. The isolation area is located in the office. Age appropriate sinks and toilets were inspected for availability and good repair in both restrooms. There are two restrooms available for children. One bathroom has 4 toilets and a trough style sink and the second bathroom has 4 toilets and 2 sinks. General sanitation was observed. Availability of indoor drinking water was observed in classrooms via water bottles.. Per Director, Teachers assist children with the drinking water if they need to re-fill their water bottles. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Per Director, there are no poisons stored at the facility and medications are stored in the office or kitchen if required. Per Director, there are no children who require medication at this time. A carbon monoxide detector and a smoke alarm were available in the facility and they are operable.

The outdoor playground area was evaluated. Outdoor equipment is in a safe condition, free of sharp, loose or pointed parts. All areas around or under high climbing equipment and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. Availability of outdoor drinking water was observed via water bottles. Per Director, the second outdoor area has not been used for about two years. LPA observed area and advised yard be made secure once it will be used again.

SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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Document Has Been Signed on 04/20/2022 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Per Director staff 1 will complete a livescan by 4/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 6 staff records that were missing a current flu vaccine which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2022
Plan of Correction
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Director stated proof of flu vaccine or declination will be submitted by due date.
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 record review and interview the licensee did not comply with the section cited above in 6 out of 6 staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Per Director all staff will complete training and submit by due date

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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2022
Plan of Correction
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per director staff 1 will complete LIC 508 and proof will be submitted by due date
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 6 out of 6 staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Per Director proof of at least one staff member who is trained in pediatric cpr/first aid will be submitted by due date.

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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff records which were missing LIC 503 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Per Director proof of LIC 503 for staff 1 will be submitted.
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff records which were missing LIC 501 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2022
Plan of Correction
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Per Director proof of LIC 501 for staff 1 will be submitted.

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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 05:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out 10 children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2022
Plan of Correction
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per director proof of medical assessment will be submitted by due date.
Type B
Section Cited
CCR
101229.1(b)
Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 7 out of 27 children present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2022
Plan of Correction
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Per Director a letter will be sent out to parents notifying of sign in/out procedure. Proof of letter will be submitted 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: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305
VISIT DATE: 04/20/2022
NARRATIVE
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Per Director there are no firearms stored on the premises. There are no pools or bodies of water at the facility. The 2A10BC fire extinguisher was last serviced on 2/2022
Director was reminded that all adults 18 and over, 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 Child Care Center. 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.
Children’s Records were reviewed for completeness. (The name, address, and telephone number of child’s authorized representative and medical assessment are on file). Inspection of required forms was made and documented on the LIC 857.
LPA also reviewed staff records. LPA observed that one staff did not have a criminal record clearance and was not associated to the facility. The review of Staff records was documented on the LIC 859. Staff present did not have proof of the AB 1207 Mandated Reporter Training certificate on file. All staff present did not have proof against TB, measles, pertussis, and influenza. All staff present did not have current training on Pediatric CPR/ First Aid.
Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. Seven out of 27 children present when LPA arrived were not signed into the facility. Disaster drill log was available, last drills were conducted on 4/13/22.
Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness and proper equipment. Menus are posted online in advance for children's authorized representatives. Menus for the past 30 days are available upon request. The facility utilizes a vendor for lunch and provides breakfast and two snacks.
First Aid supplies are available in each classroom and one is available outside accessible to staff. Incidental Medical Services (IMS) policy was discussed. LPA provided PIN 22-02-CCP For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: TRINITY LUTHERAN PRESCHOOL & DAY NURSERY
FACILITY NUMBER: 191502305
VISIT DATE: 04/20/2022
NARRATIVE
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LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the
inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/tion-process. A current email address was collected during today's visit.
The deficiencies listed on the following page were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility. A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility. Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and Appeal Rights and report were reviewed with the Director Debbie Torres.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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