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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418346
Report Date: 06/09/2021
Date Signed: 06/09/2021 01:20:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BETHLEHEM LUTHERAN SCHOOLFACILITY NUMBER:
197418346
ADMINISTRATOR:FERRARA, TONIFACILITY TYPE:
850
ADDRESS:27265 LUTHER DRIVETELEPHONE:
(661) 251-6027
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY:98CENSUS: 29DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Toni Ferrara, DirectorTIME COMPLETED:
01:30 PM
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On 06/09/2021, Licensing Program Analyst (LPA) Monique Ayala met with the Director for the purpose of conducting an unannounced Annual/Random inspection. LPA toured and inspected the entire center, which consist of 5 classrooms, 5 bathrooms, office/reception area and outdoor play yard. Present during this inspection were 4 teachers with 29 preschool children. The facility operates from 6:30 am to 6:00 pm Monday through Friday.

First Aid and CPR, expiration date 09/12/2021.

Furniture and equipment were inspected for age appropriateness and good repair. Outdoor playground was clean and free of debris. Center provides potty training. There was a changing table present, and a sink within arms reach in classroom 1. Bedding and linens were individually stored so that each child's bedding is identifiable, and no child's used bedding comes into contact with other bedding.

There is a clean, fully equipped kitchen (off limits) with refrigerator, freezer (1), stove and microwave oven. Parents provides breakfast and lunch, center provides snacks if needed. Allergy lists are posted in classrooms.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BETHLEHEM LUTHERAN SCHOOL
FACILITY NUMBER: 197418346
VISIT DATE: 06/09/2021
NARRATIVE
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LPA observed an appropriate amount of food and snacks. Cleaning solutions are stored separately away from the food (kitchen locked cabinet).

Sign in and out sheets were reviewed. The parent board was reviewed and has all of the required forms posted. LPA observed the Fire/earthquake drills current.

Children's records and staff records were reviewed.

LPA observed a fully stocked first aid kit; fully charged fire extinguishers; carbon monoxide detectors throughout the center.

The following general information was discussed during this inspection:

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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. Center does not provide IMS at this time.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BETHLEHEM LUTHERAN SCHOOL
FACILITY NUMBER: 197418346
VISIT DATE: 06/09/2021
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Mandated Reporter Training Requirements: §1596.8662 - As of January 1, 2018, child care providers, administrators, or employees who work in a licensed 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. Staff was informed that they need to take mandated reporter training.

Immunization Requirements: §1596.7995 (a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.



*All Licensing reports are available for review on-line and are considered public information. Summary: Assembly Bill 2621 added Section 1596.819 to the Health and Safety Code, to require the Department to post certain licensing information for CCCs and FCCHs on its public internet website.

Safe Sleep Information: California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP – Safe Sleep Campaign: http://www.healthychildcare.org/sids/html
AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Rick-of-SIDS-in-Early-Education-and-Child-Care
And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BETHLEHEM LUTHERAN SCHOOL
FACILITY NUMBER: 197418346
VISIT DATE: 06/09/2021
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Fingerprint clearances and transfers: Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. If a fingerprint clearance has been obtained through the Department, Licensee may request a transfer of a criminal record clearance from one state licensed facility to another using form LIC 9184

The following Type A deficiency was issued today for, Criminal Record Clearance 101170(e)(2). S1 was working at the facility without criminal record clearance.

Upon receipt of a Type A deficiency the licensee shall post the report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. If these requirements are not met, civil penalties will be assessed.


Exit interview conducted and a copy of this report was left at the facility, along with appeal rights and Notice of Site Visit. A copy of this report must be made available to the public for 3 years.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BETHLEHEM LUTHERAN SCHOOL
FACILITY NUMBER: 197418346
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited

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101170(e)(2): 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... (2)Request a transfer of a criminal record clearance. This requirement was not as evidence by:
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Based on observation and record review: Licensee did not ensure Staff 1 completed the criminal record transfer request prior to working at the facility which poses an immediate Health and Safety Risk to 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: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5