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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191503710
Report Date: 02/12/2020
Date Signed: 02/12/2020 11:27:39 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2020 and conducted by Evaluator Jennifer Hua
COMPLAINT CONTROL NUMBER: 33-CC-20200205145105
FACILITY NAME:MT. CALVARY LUTHERAN PRESCHOOL & DAY CARE CENTERFACILITY NUMBER:
191503710
ADMINISTRATOR:GEORGETTE DELGADOFACILITY TYPE:
850
ADDRESS:23300 EAST GOLDEN SPRINGS DR.TELEPHONE:
(909) 861-2740
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:72CENSUS: 56DATE:
02/12/2020
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Georgette DelgadoTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff did not notify authorized representatives of unusual incident
Staff are not able to maintain proper temperature in facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Hua conducted an unannounced site inspection on this date to investigate the above complaint allegations. Met with Director Georgette Delgado, who guided analyst tour of the facility.
During this inspection interview was conducted with director. Director confirmed the following: On 1/17/20, facility was without running water from 3:45pm - 6pm due to a water line ruptured causing a water leak. Water was shut off to the preschool building for the remainder of the day. On 2/5/20, a portion of the city lost power from 12:15pm - 2:30pm. Due to lack of light, the classroom doors were opened for the 12:15 - 12:55 timeframe to allow the children proper lighting to finish lunch. Therefore, proper room temperature was not maintained. Doors were closed during naptime (1pm -3pm). Director stated that parents were notified through Gradelink regarding the power outage and not the water shut off. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 33-CC-20200205145105
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL & DAY CARE CENTER
FACILITY NUMBER: 191503710
VISIT DATE: 02/12/2020
NARRATIVE
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The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview conducted with director. Appeal Rights explained and provided.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 33-CC-20200205145105
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL & DAY CARE CENTER
FACILITY NUMBER: 191503710
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2020
Section Cited
CCR
101239(a)(1)
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Fixtures, Furniture, Equipment and Supplies. A comfortable temperature for children shall be maintained at all times. The licensee shall maintain the temperature in rooms that children occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). The requirement is not met as evidenced by: Per director, on 2/5/20 a
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Deficiency was ccorrected after power came back on.
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portion of the city lost power from 12:15pm - 2:30pm, classroom doors were open from 12:15pm -12:55pm, to allow proper lighting for children to finish lunch.Therefore, the room temperature was not properly maintained. This poses a potential risk to the healh and safety of children in care.
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Type B
02/12/2020
Section Cited
CCR
101212(d)(1)(C)(f)
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Reporting Rquirements. Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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Per licensee, will report all incidents to parents and the Department in a timely manner from now on to ensure compliance.
Copy of incident reports obtained during visit.
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The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.The requirement is not met as evidenced: Incidents were not reported to the Department and parents. This poses a potential risk to the healh and safety of chidlren 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: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3