300600812-4-14-2022-06-CC-PMAA-CDPVT6-20220421164233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300600812
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:47:45 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2022 and conducted by Evaluator Mila Quinto

COMPLAINT CONTROL NUMBER: 06-CC-20220210140531

FACILITY NAME:	PRINCE OF PEACE LUTHERAN NURSERY SCHOOL		FACILITY NUMBER:	300600812
ADMINISTRATOR:	MILLA, MARIA		FACILITY TYPE:	850
ADDRESS:	1421 WEST BALL ROAD		TELEPHONE:	(714) 774-0993
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	72	CENSUS: 19	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Milla, Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not notify daycare child’s authorized representative of incident involving daycare child.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Mila Quinto and Patricia Duron conducted an investigation visit to the facility to deliver the findings. LPA met with Director, Maria Milla. The Covid-19 Emergency Response questionnaire was reviewed and answered by the director. Census was taken. There was a total of 19 preschool children with 5 staff in different classrooms.

A review of facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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 06-CC-20220210140531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PRINCE OF PEACE LUTHERAN NURSERY SCHOOL	FACILITY NUMBER: 300600812
	VISIT DATE: 04/14/2022

NARRATIVE

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Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The complainant alleged staff did not notify daycare child’s authorized representative of incident involving daycare child. According to the complainant, Child 1 got hurt at school and the facility did not provide an incident report.

On 2/15/22, LPA interviewed 3 staff members including the director and 7 preschool children. The director stated an ouch/incident report is completed even for minor injuries and given to the parents. The 2 staff indicated depending on the injury will determine if an ouch/incident report is completed to provide the parents. LPA reviewed C1’s file and there was no incident report on file. The director indicated the staff may have forgotten to write one since the parent was notified during pick up time.

On 3/8/22, LPA called 10 parents, LPA was able to interview 4 of the 10 parents. 1 of the 4 parents disclosed they do not receive incident reports from the facility for behavior or injuries. The 3 of 4 parents did not make any disclosures. LPA did not receive a call back from the 6 parents.

This agency has investigated the complaint alleging Staff did not notify daycare child’s authorized representative of incident involving daycare child. The preponderance of evidence standard has been met; therefore, the above allegation of is found to be SUBSTANTIATED.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Director was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 06-CC-20220210140531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PRINCE OF PEACE LUTHERAN NURSERY SCHOOL	FACILITY NUMBER: 300600812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/14/2022 Section Cited CCR 101212(f)	1 2 3 4 5 6 7	101212(f) Reporting Requirements The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative. This requirment is not met as evidenced by:	1 2 3 4 5 6 7	The director will conduct a meeting with all staff regarding the reporting requirements and cover the incident reports to be provided to the authorized representatives. The Director will provide the staff meeting agenda by April 22, 2022
	8 9 10 11 12 13 14	Based on interview and file review, the facility did not report to parent, however first aid was provided. The facility failed to report incidents to authorized representaties. This poses a potential safety risk to children in care.	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: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Mila Quinto	TELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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