<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602295
Report Date: 11/03/2022
Date Signed: 11/03/2022 03:34:25 PM


Document Has Been Signed on 11/03/2022 03:34 PM - It Cannot Be Edited

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:HEPHATHA LUTHERAN CHURCH PRESCHOOLFACILITY NUMBER:
300602295
ADMINISTRATOR:MORA, TERIFACILITY TYPE:
850
ADDRESS:5900 E SANTA ANA CANYON RDTELEPHONE:
(714) 637-0887
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY:97CENSUS: 20DATE:
11/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Teri Mora, DirectorTIME COMPLETED:
03:30 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) Stacy Torrence conducted an unannounced Case Management visit. LPA met with Teri Mora, Director, to discuss the Lead Sampling Testing conducted on 09/28/2022. Director was advised on 10/27/2022 that the Lead Sample Report was to be posted. LPA confirmed that Director had posted the Lead Sample Report.

Director stated the outlet with the high level of Lead is located on the playground, has not been in operation for at least 3 years. During today’s inspection, LPA Torrence observed the outlet inoperable, as the outlet is turned off, tape and plastic around it, with an Not In Use sign taped over it. Source of drinking water is available by the children bringing their own water bottles from home, labeled with their names and in every classroom and on the playground, there are gallons of filter water available refills.

Exit interview conducted and report was reviewed with the facility representative Teri Mora. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights were explained. The Licensee was provided a copy of 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 Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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 2


Document Has Been Signed on 11/03/2022 03:34 PM - It Cannot Be Edited

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: HEPHATHA LUTHERAN CHURCH PRESCHOOL
FACILITY NUMBER: 300602295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2022
Section Cited

1
2
3
4
5
6
7
101700.3(b)(1) California Lead Action Level of Child Care Centers. (b) Testing results with fractional ppb readings of 0.5 ppb or greater ……. (1) shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
 Based on facility Lead sampling testing it was discovered that one outlet located in on playground had a high level of lead. This poses a potential risk to the health of children in care.
8
9
10
11
12
13
14

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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2