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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191571666
Report Date: 06/12/2019
Date Signed: 06/12/2019 03:50:23 PM

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:HOLY TRINITY LUTHERAN CHURCH PRESCHOOLFACILITY NUMBER:
191571666
ADMINISTRATOR:SOPHIA GARCIAFACILITY TYPE:
850
ADDRESS:15710 NEWTON STREETTELEPHONE:
(626) 961-2070
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:73CENSUS: 44DATE:
06/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Sophia GarciaTIME COMPLETED:
03:55 PM
NARRATIVE
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Random Site inspection was conducted on this date by Licensing Program Analyst, Jennifer Hua, who met with director Sophia Garcia, who guided analyst on a complete tour of the facility. There are a total of 5 classrooms. 4 for preschools, 1 for toddler option. Facility operates M-F 6:30am - 6pm.

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 and an isolation area with a sink, toilet, and mats/cots was inspected. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed.

Outdoor equipment was inspected for safety, cushioning material, good repair and age appropriateness. Required shade, drinking water and fencing were inspected. Play area was inspected for hazards and inaccessibility to bodies of water.

Snack/lunch menus were reviewed. Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness. A review of cleaning and food supply storage areas was made.
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Teacher child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met.

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SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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: HOLY TRINITY LUTHERAN CHURCH PRESCHOOL
FACILITY NUMBER: 191571666
VISIT DATE: 06/12/2019
NARRATIVE
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Staff and children records were reviewed for completeness including but not limited to Criminal Record Clearances for adults, Director Qualifications and verification of CPR/First Aid and health preventive practices documentation. Review of required forms was made. All staff completed the Mandated Reporter Training. Licensee was informed training shall be renewed every 2 years.

A review of all facility staff or other individuals who require caregiver background checks was conducted on this date to determine if they have received criminal record and child abuse index clearances or exemptions and/or have provided proof of submission of finger prints to DOJ, FBI and CAIC. MOST RECENT EXEMPTION REGULATIONS DISCUSSED.

This 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 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

INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.

Deficiencies cited on attached 809D.

Per Licensee, will submit IMS plan to the department by 7/12/19.

An exit interview conducted with director, copy of report given. Appeals rights provided and explained.

Notice of Site Visit form was provided and explained. The notice shall be posted for 30 days or a civil penalty of $100 shall be assessed.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLY TRINITY LUTHERAN CHURCH PRESCHOOL
FACILITY NUMBER: 191571666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2019
Section Cited
CCR
101229.1(b)
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Sign In and Sign Out. The person who brings the child to, and removes the child from, the center shall sign the child in/out. The requirement is not met as evidenced by: LPA observed in Blue room, 2 children was not signed in. In Toddler room, 1 child was not signed in. This is a potenital risk to the health and safety of children in care.
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Per licensee, will monitor closely, remind parents and inform staff to remind parents as well.
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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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
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: HOLY TRINITY LUTHERAN CHURCH PRESCHOOL
FACILITY NUMBER: 191571666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2019
Section Cited
CCR
101226(e)(2)
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Health-Related Services. All prescription and nonprescription medications shall be maintained with the child's name and shall be dated. The requirement is not met as evidenced by: LPA observed Epi-Pen Jr. for child #1- expired in April 2019. This poses a potential risk to the health and safety of chidlren in care.
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Per licensee, will get a new epipen from parent the next day child is in care.
Type B
06/28/2019
Section Cited
HSC
1596.7995(c)
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Required Immunizations. Effective 9/1/16, all staff and volunteers are required to maintain proof of influenza, Pertussis and Measles immuniations on file. The requirement is not met as evidenced by: 1 staff lack Measles record in file. This poses a potential risk to the health and safety of children in care.
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Per licensee, will maintain copy and submit copy to LPA by the POC due date of 6/28/19
Type B
06/28/2019
Section Cited
CCR
101216.1(g)
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Teacher Qualifications and Duties. 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. The requirement is not met as evidenced by: 2 teachers lack the 3 semester units in Child,
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Per licensee, will maintain copy and submit copies to LPA by the POC due date of 6/28/19.
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Family and Community transcript in file. This poses a potential risk to the health and safety of children 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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2019
LIC809 (FAS) - (06/04)
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