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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191503710
Report Date: 04/19/2022
Date Signed: 04/19/2022 12:20:59 PM


Document Has Been Signed on 04/19/2022 12:20 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754



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: 41DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Janet Ramirez (Diaz)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jennifer Hua conducted an unannounced Required - 1 year inspection. Upon arrival, LPA met with Janet Ramirez, teacher in charge. A COVID-19 risk assessment was conducted prior to entry to the facility. LPA provided Ms. Ramirez with a copy of the LIC 125 Entrance Checklist to facilitate the inspection. This is a preschool program. Facility also has a licensed Infant Program #198020075. Business hours are from Monday-Friday, 6:30 AM to 6:00 PM. Per teacher, director is on vacation and will return next Monday.

LPA was guided to a facility tour by teacher in charge. All areas identified on the Facility Sketch were inspected. There are of total of 3 classrooms, and each room is divided into 2 rooms. LPA observed the following: Room #1, 12 kids with 1 staff, Room #1B - is empty, Room #2, 9 children with 1 staff, Room #2B, 8 children with 1 staff, Room#3, 12 children with 2 staff, Room#3B is empty.
The facility was observed to be within the license capacity and limitations. Children's roster was reviewed. Sign-In and Sign-Out sheets were reviewed.

Rooms identified on facility sketch were inspected Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Napping equipment and bedding were inspected. Storage for children's belongings. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed.

A first aid kit is kept in each classroom. Carbon monoxide detectors and smoke detectors are present in the facility. Fire extinguishers are serviced annually. Storage cabinet in classrooms was locked and hazardous items including cleaning compounds were stored inaccessible to children.

Report continues to next page
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL & DAY CARE CENTER
FACILITY NUMBER: 191503710
VISIT DATE: 04/19/2022
NARRATIVE
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Children bring their own lunch, the lunch bags are stored in their cubby or parents can order online through Southland Catering lunch program. Morning and afternoon Snacks are offered, children also have an access to water fountain and also carry their own water bottles which were observed to be placed on table or in their cubby.

Outdoor equipment was inspected for safety, cushioning material, good repair and appropriateness. Required shade, drinking water and fencing were inspected. The children have access to drinking water during outside play was observed on site. Play area was inspected for hazards and inaccessibility to bodies of water. There is no bodies of water on site. Director and staff are current in Pediatric CPR and First Aid are on file for most staff & Director. Certificate are issued by the American Heart Assocation.

Teacher child ratios were observed, and staff names recorded. Care and supervision were evaluated to determine if the basic needs of children are met and appropriate.

Staff and Children’s Records were reviewed. Criminal Record Clearances were reviewed for adults for required transfers and associations. LPA staff #1 does not have fingerprint clearance on file.All staff files reviewed have met the Immunization requirements.

The facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation and Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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
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: 04/19/2022
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Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed and observed. Role and responsibilities of being a Mandated Reporter were reviewed. The Director was advised how to access forms and Regulations online at www.ccld.ca.gov. Director was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care.

LPA advised that all staff 18 years of age and older providing Care & Supervision and/or have continuous presence in the facility shall adhere to a criminal background clearance with the Department of Justice, FBI and Child Abuse Index Check.

Per teacher, isolation area in the director's office.

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.

Upon receipt of this report documenting a Type A deficiency, the licensee shall do the following:


1. Post the Notice of Site visit and any licensing report documenting a Type “A” deficiency.
2. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.
3. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year).
4. The Acknowledgement form (LIC 9224) must be maintained in each child’s file immediately upon receipt from parent. A copy of the parent Acknowledgement of Receipt of Licensing Reports Form was provided during this visit.

Deficiencies cited on attached 809D. Exit interview conducted and report was reviewed with teacher Janet Ramirez. NOTE: Licensee to submit updated LIC 309 by 5/19/2022.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/19/2022 12:20 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 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: 04/19/2022

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 record review], the licensee did not comply with the section cited above. LPA observed that Angelica Cortez has been employed since 9/7/2021 and fingerprint clearance not on file. LPA also contact the Licenisng office and was inforrmed that the Licensing system shows shat individual information is closed and fingerprints not taken. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Per teacher, will have individual get livescan immediately and will not return until clearance is received.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/19/2022 12:20 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 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: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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) (record review)], the licensee did not comply with the section cited above. LPA observed staff #1, did not complete training. Staff 3, 4, and 7 certificated expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Per teacher, will have staff complete and renewed and submit copy of certificates to LPA by the POC due date of 4/29/2022
Type B
Section Cited
CCR
101216.1(g)
Teacher Qualifications and Duties
(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (record review)], the licensee did not comply with the section cited above. LPA observed staff #1's educational transcripts available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Per teacher, will submit copy of transcripts by the POC due date of 4/29/2022

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) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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