300602027-11-20-2019-06-CC-JMHN-BJ4PRK-20191120103252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 11/19/2019
Date Signed: 11/20/2019 10:33:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	SALEM LUTHERAN PRESCHOOL		FACILITY NUMBER:	300602027
ADMINISTRATOR:	VICKERS, KATHY		FACILITY TYPE:	850
ADDRESS:	6411 EAST FRANK STREET		TELEPHONE:	(714) 639-1946
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	101	CENSUS: 23	DATE:	11/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Kathy Vickers		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA), Jungmi Han conducted an unannounced annual/random inspection of the facility on today's date. LPA Han toured the facility with the director, Kathy Vickers inside and outside. Census was taken in individual classrooms. The overall census observed was 6 preschool staff and 23 preschool children. A review of staff criminal clearance records 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. Operating hours are 7:00 am- 6:30 pm, Mon-Fri. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Director stated the facility changed room number in 8/2019. Previous (before 8/2019) Room# Current Room# (after 8/2019) A4 A3 A5 A4 A6 A5 A7 A6 B5 B4 B6 B5 Director submit change room number information statement and updated facility sketch to LPA during inspection. LPA Han observed A2 (previously called room A9) and that is not on the license. Director stated it is used by 2-3 years old preschool children and there are currently 8 children enrolled. LPA Han reviewed files and previous reports, but couldn't find information about room A2 (or A9 before 8/2019) that has been approved to use for preschool children. Director stated room A2 has been used 1994-2011, 2015, 2018, 2019. Facility did not use A2 in 2012, 2013, 2014, 2016, 2017. Director was told that A2 is allowed up to 9 children by previous director. Director was informed that LPA Han will investigate the issue. Page 1 of 3

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SALEM LUTHERAN PRESCHOOL	FACILITY NUMBER: 300602027
	VISIT DATE: 11/19/2019

NARRATIVE

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The items which could pose a danger to children detergents, cleaning compounds, and medications were stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Snacks are prepared and provided on site. Lunches are provided by 3^rd vendor. Food prep areas appear clean and sanitary. Food is properly stored. On site kitchen is free from hazards. The toys, floors, desks and other equipment appeared clean. There is drinking water available to children both indoors and outdoors. The children's bathrooms are clean and sanitary. Children nap on mats and bedding is taken home weekly to be washed by parents. The facility has conducted an emergency drill within the past six months. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground was completely fenced. The playground equipment appeared in safe condition. There is sufficient cushioning underneath climbing structures and play equipment to absorb falls.

Sign in/out procedure was reviewed for compliance. During today's visit staffing ratios were being met. At least one staff member present possesses current CPR/First Aid certifications, which expires 8/2020. Children's and staff files were reviewed for compliance. Children's and staff files were in substantial compliance.

The facility does provide Incident Medical Services.
This facility provides Incidental Medical Services – IMS. 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

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.
Proof of immunizations against pertussis and measles for all employees/volunteers were reviewed for compliance with SB 792.
Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.
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SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SALEM LUTHERAN PRESCHOOL	FACILITY NUMBER: 300602027
	VISIT DATE: 11/19/2019

NARRATIVE

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A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
Always place infants on their backs for sleeping
Use only a tight-fitting sheet on the crib or play yard mattress
Do not hang any items from the crib or above the crib
Keep all items, including blankets, out of the crib or play yard
Pacifiers may be used as long as they do not have items attached to them
Infants should not be swaddled or have any items covering them while sleeping
The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

Provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

The facility representative was informed that the CRIMINAL RECORD STATEMENT (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. The facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182). The facility representative was informed that Licensing Updates are available at www.ccld.ca.gov
Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. Appeal Rights and deficiencies were discussed. The director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov

The 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 $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

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