<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414470
Report Date: 12/12/2019
Date Signed: 12/12/2019 05:31:18 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:SHEPHERD OF THE VALLEY LUTHERAN CHURCHFACILITY NUMBER:
197414470
ADMINISTRATOR:SHIRLEY BELLMANFACILITY TYPE:
850
ADDRESS:23838 KITTRIDGE STREETTELEPHONE:
(818) 348-8343
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:80CENSUS: DATE:
12/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Claudia Salavan, DirectorTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/12/2019 at 2:20pm, Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced case management – incident visit at Shepherd of the Valley Lutheran
Preschool for the purpose of following up on the self reported unusual incident with date and time unclear that child#1 pulled down and hit/tapped the private area of the child#2.

The unusual incident was reported via phone call to the El Segundo Regional Child Care Office on 12/06/2019 and during this visit, Director Assistant provided a copy of the LIC 624 Unusual Incident/Injury Report (UIR). Upon arrival, LPA met with Director Assistant Ms. Claudia Zavala Lanz and informed the nature of the visit. There were a total of 38 children being supervised by 13 teachers and 3 teachers aide.



In additional, LPA obtained the following document:
Emergency card form. (child#1 and #2)
The following documents will bel provide by Director Assistant no later than tomorrow 12/13/19:
Roster, attendance sheet, children - Sign in and Sign out.

Based on the facts gathered and interviews conducted. At this time needs further investigation.
An exit interview was conducted, a copy of this report and notice of site visit provided to the Director Assistant, Claudia Zavala Lanz.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1