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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603677
Report Date: 03/05/2020
Date Signed: 03/05/2020 12:20:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HOLY TRINITY LUTHERAN CHILD CARE CENTERFACILITY NUMBER:
191603677
ADMINISTRATOR:ANDREA PENNFACILITY TYPE:
850
ADDRESS:9300 CRENSHAW BLVDTELEPHONE:
(323) 757-4850
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY:85CENSUS: 40DATE:
03/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Andrea Penn, DirectorTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shandra Powell conducted an unannounced case management inspection during a complaint investigation.

LPA was met by Andrea Penn, Director. During this inspection LPA observed that the children's sign in and out sheet had 8 missing signatures of Authorized Representatives. This poses a potential risk to the health and safety of children in care.

Director disclosed to LPA during inspection she has signed the children in due to child's Authorized Representative not signing the child in. LPA advised director not to sign the children in or out. Per regulation The person who brings the child to, and removes the child from, the center shall sign the child in/out.


The following deficiencies listed on the attached deficiencies page is being cited in accordance with California Code of Regulations Title 22.

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 was conducted with Andrea Penn, Director, Appeal Procedures given and explained.

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOLY TRINITY LUTHERAN CHILD CARE CENTER
FACILITY NUMBER: 191603677
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2020
Section Cited

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Sign in and Sign Out
The person who signs the child in/out shall use his/her full legal signature and shall record the time of day. The person who brings the child to, and removes the child from, the center shall sign the child in/out.

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In review of sign in and sign out sheets, LPA
observed that 5 children were not signed in by an Authorized Representative. This poses an 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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
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