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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191603677
Report Date: 03/05/2020
Date Signed: 03/05/2020 12:10:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2020 and conducted by Evaluator Shandra Powell
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20200211161607
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
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Andrea Penn, DirectorTIME COMPLETED:
12:08 PM
ALLEGATION(S):
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Lack of supervision resulting in child sustaining multiple injuries while in care.
Incident report was not submitted.
INVESTIGATION FINDINGS:
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An unannounced site visit was conducted by Licensing Program Analyst (LPA) Shandra Powell to complete complaint investigation for allegation of Lack of supervision resulting in child sustaining multiple injuries while in care and Incident report was not submitted. LPA met with Director Andrea Penn. LPA observed 40 children in care.

Based on interviews conducted with staff and other parties involved and review of documentation and disclousure of Staff the above allegation of Lack of supervision resulting in child sustaining multiple injuries while in care are substantiated. As for reporting requirement licensee did not report unusual incident to the department. Therefore, the above allegations of Lack of supervision resulting in child sustaining multiple injuries while in care and reporting requirement are deemed substantiated. LPA observed 3 Ouch Reports for child during file review.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 30-CC-20200211161607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/05/2020
NARRATIVE
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Facility is cited per California Code of Regulations, Title 22, Regulations (see attached LIC 9099D) .

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). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224) Form during this visit.

The Director was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days with report.

Exit interview was conducted and a copy of the report was issued to Director, Andrea Penn and Appeal Rights provided.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 30-CC-20200211161607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
03/12/2020
Section Cited
CCR
101229(a)(1)
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Responsibility of providing care and supervision - The licensee shall provide care and supervision as necessary to meet the children's needs... Supervision shall include visual observation.
The requirement is not met as evidenced
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by interviews with staff and record review staff did not observe injury of child while in class room. This poses an immediate 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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 30-CC-20200211161607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
03/06/2020
Section Cited
CCR
101212(d)
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Reporting Requirements.

A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified.
This requirement has not been met as evidenced
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by LPA review of children's files and interview of staff. Injured child was not reported to the Department

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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2020 and conducted by Evaluator Shandra Powell
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20200211161607

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
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Andrea Penn, DirectorTIME COMPLETED:
12:08 PM
ALLEGATION(S):
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2
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9
Facility staff failed to inform child's parent of unusual incidents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shandra Powell conducted an unannounced Complaint Inspection to conclude the investigation regarding the above complaint allegations. Upon arrival, LPA met with Andrea Penn, Director, Census was taken.

This agency has investigated the complaint alleging, Staff failed to inform child's parent of unusual incidents. During investigation LPA observed signed Ouch Reports in child's file by child's representative. Dates on Ouch Reports match complaintants dates of of incidents (allegations).

Based on the evidence obtained during the investigation through interviews with staff, and record review the evidence does not support, nor disprove the above allegations of, facility staff failed to inform child's parent of unusual incidents. Therefore, the allegation is determined to be unsubstantiated. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.


Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 30-CC-20200211161607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/05/2020
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 was conducted with Andrea Penn, Director, Appeal Procedures explained and provided.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 6