197494908-2-23-2022-30-CC-CESO-CBYSV9-20220225131222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197494908
Report Date: 02/23/2022
Date Signed: 02/23/2022 12:27:39 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
01/31/2022 and conducted by Evaluator Lisa Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 30-CC-20220131104740

FACILITY NAME:	WESTCHESTER LUTHERAN LEARNING CENTER		FACILITY NUMBER:	197494908
ADMINISTRATOR:	SHIRLEY BECKER		FACILITY TYPE:	830
ADDRESS:	7831 S SEPULVEDA BLVD		TELEPHONE:	(310) 670-5422
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	24	CENSUS: 6	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Director Shirley Becker		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Personal Rights-
Facility did not meet infant's diapering needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lisa Rios conducted an unannounced visit to the Westchester Lutheran Learning Center on 2/23/22 at 11:30am for delivering the findings to the Director Shirley Becker of complaint allegation concerning claims as mentioned above.

Based on the interviews recorded on LIC812 dated 2/3/22 during the investigation of a complaint recorded on LIC802 dated 1/31/22, and documentation received there was sufficient information to support that the above allegation occurred. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Facility did not meet infant’s diapering needs is SUBSTANTIATED.

There is one type A deficiency, 101428(b)(2), cited per California Code Regulation, TITLE 22, DIVISION 12, CHAPTER 1, ARTICLES 1-7.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 30-CC-20220131104740

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: WESTCHESTER LUTHERAN LEARNING CENTER	FACILITY NUMBER: 197494908
	VISIT DATE: 02/23/2022

NARRATIVE

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On 1/12/22 infant was at facility for 8 ½ hours and documentation of diaper change was once. Infant’s NSP states that the infant eats 16-20oz of formula day and needs 6-10 diaper changes.

On 1/28/22 infant was at the facility for 6 hours and diaper was changed once.

On 2/8/22 P6 stated that infant was changed twice in 8 hours. The infant's Needs and Service Plan states that the infant eats 12 oz a day and needs 5 diaper changes.

On 2/15/22 P10 stated that infant was changed twice and in attendance for 8 hours. The infant's Needs and Service Plan states that infant eats 16oz a day and needs 5-6 diaper changes.

LPA Rios informed Director Shirley Becker that this report dated 2/23/22 Notice of Site Visit which documents a Type A citation must be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Rios informed Director Shirley Becker to provide a copy of this licensing report dated 2/23/22 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview was conducted and a copy of this report and appeals rights were emailed to the Director for signature.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 30-CC-20220131104740

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: WESTCHESTER LUTHERAN LEARNING CENTER	FACILITY NUMBER: 197494908
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/23/2022 Section Cited CCR 101428(b)(2)	1 2 3 4 5 6 7	101428(b)(2) Infant Care Personal Services (b)The infant shall be kept clean and dry at all times. (2)Each infant's clothing and diapers shall be changed as often as necessary to ensure that the infant is clean and dry at all times.	1 2 3 4 5 6 7	The Director shall submit 2 weeks of diaper change documentation for all infants from Brightwheel no later than March 10th, 2022 to LPA Rios at lisa.rios@dss.ca.gov.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on idocuments received of days and times of diaper changes made, review of Infant Service Needs Plans, interview with RP, P6 and P10 the infant’s diapering needs are not always met.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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