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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012116
Report Date: 09/13/2019
Date Signed: 09/13/2019 10:43:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:LUTHERAN INTERNATIONAL SCHOOLFACILITY NUMBER:
198012116
ADMINISTRATOR:JENNIFER AGBAYANIFACILITY TYPE:
850
ADDRESS:5032 N. MAYWOOD AVENUETELEPHONE:
(323) 257-7547
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY:45CENSUS: 24DATE:
09/13/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jennifer Agbayani TIME COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Judy Mora conducted an unannounced Annual random inspection. LPA met with designated facility Director,Jennifer Agbayani, who guided LPA on a tour of the facility. This is a preschool age program licensed for 45 children which operates Monday – Friday from 7:00 AM – 6:00 PM. Per the Director there are 35 children enrolled.

All areas identified on the facility sketch were inspected. Upon arrival, LPA observed 15 children with 02 staff outdoors and 02 children with 01 staff in the Purple Room. More children arrived during the tour. Teacher-child ratios were observed to be in accordance with Title 22 regulations. The Licensee is within the conditions, limitations, and capacity specified on the license. Staff names were recorded. All children were observed to be under visual supervision of a teacher at all times.

Furniture and equipment was inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All toilets and hand washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free. At this time, the office is used as an isolation area. Parents are contacted immediately when children are determined to be ill.

Snack menus were reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative. The facility provides AM snack and PM snack. Children bring their own lunches. All kitchen, food preparation, and storage areas are clean, free of litter, rubbish, and rodents/vermin. All food is protected from contamination. There is drinking water available in all indoor classrooms and a water machine and disposable cups are available outdoors. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. Storage areas for poisons are locked.

*REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LUTHERAN INTERNATIONAL SCHOOL
FACILITY NUMBER: 198012116
VISIT DATE: 09/13/2019
NARRATIVE
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 Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. The licensee takes measures to keep the facility free of flies, other insects and rodents.

Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is maintained in a safe condition as is free of hazards. Areas around and/or under climbing equipment, swings and slides have rubber cushioning material to absorb a fall. Director states there are no weapons or firearms on the premises. The Director states that there are no bodies of water on the premises and LPA did not observe any bodies of water during this visit.

Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. LPA observed that at the time of review, 21 children were present and only 17 children were signed in; this is a potential risk to the health and safety of children in care. Staff Records were reviewed to ensure that a health screening report is on file. During staff file review, LPA observed 2 staff missing health screening reports. Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.



SB792 Immunization Requirements for Staff and Employees was discussed with the Director. All staff have required immunization documentation on file.

AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: https://www.mandatedreporterca.com/training/child-care-providers. Director and staff have not completed the training as required.

This facility provides Incidental Medical Services – IMS. Plan of Operation was submitted to the Department. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

*REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LUTHERAN INTERNATIONAL SCHOOL
FACILITY NUMBER: 198012116
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2019
Section Cited

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Sign in and Sign Out
The person who brings the child to, and removes the child from, the center shall sign the child in/out.
This requirement was not met as evidenced by LPA observing 21 children present and only 17 children signed in. This is a potential risk to the health and safety of children in care.
Type B
09/23/2019
Section Cited

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Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:A health screening.
This requirement was not met as evidenced by staff file review. LPA observed that 2 staff do not have a health screening on file.
Type B
10/29/2019
Section Cited

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Mandated Reporter Training (AB1207)
On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a),
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and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
This requirement was not met as evidenced by staff file review. LPA observed that staff have not completed the training. This is 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LUTHERAN INTERNATIONAL SCHOOL
FACILITY NUMBER: 198012116
VISIT DATE: 09/13/2019
NARRATIVE
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LIC 311-RECORDS TO BE MAINTAINED AT THE FACILITY ISSUED TO DIRECTOR.

REMINDER: Failure to obtain a criminal record background check clearances prior to initial presence in the facility will result in an immediate $100.00 dollar or more per day Civil Penalty.

LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

LPA provided email address in order to be placed on quarterly update subscription: ChildCareAdvocatesProgram@dss.ca.gov

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.

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 Director, Jennifer Agbayani. Appeal Rights and Procedures explained and provided.

*END OF REPORT

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4