300603211-3-9-2022-06-CC-JHAN-CCQS8B-20220321133847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300603211
Report Date: 03/09/2022
Date Signed: 03/09/2022 01:06:40 PM

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
01/18/2022 and conducted by Evaluator Carmen Odom

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20220118155335

FACILITY NAME:	LIGHT OF CHRIST LUTHERAN PRESCHOOL		FACILITY NUMBER:	300603211
ADMINISTRATOR:	GROBELCH, SHERYL		FACILITY TYPE:	850
ADDRESS:	18182 CULVER DRIVE		TELEPHONE:	(949) 786-3997
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	64	CENSUS: 40	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Brenda Ruiz - Staff		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff not wearing Face Coverings in childcare
Reporting Requirements

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Odom conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 01/26/2022. Upon arrival LPA met with Staff, Brenda Ruiz, to deliver complaint findings. Staff guided LPA on a tour of the facility. LPA observed a total of 40 children and 7 staff; 6 preschool children in Room #3 (2 year old) with 2 Staff, 9 preschool children in Room #2 (3 year old) with 1 Staff, 9 preschool children in Room #1 (4 year old) with 1 Staff, 13 preschool children in Room #4 (5 year old) with 2 Staff, and 3 preschool children in Room #5 (5-6 year old) with 1 staff.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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-20220118155335

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: LIGHT OF CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300603211
	VISIT DATE: 03/09/2022

NARRATIVE

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The department received a complaint on 01/18/22, Complainant Party (CP) alleging staff not wearing face covering in the childcare and not reporting COVID-19 positive cases. CP stated, on 1/10/22 Child #1 (C1) tested COVID-19 positive and C1 was exposed at the childcare center because the childcare center remains open after 6 COVID-19 positive cases in the childcare. CP disclosed they have observed staff not wearing face coverings during pick up.

During the investigation LPA Odom interviewed complaining party, director, and 2 staff members. LPA reviewed the Children’s Roster, Personnel Report, facility COVID-19 policies, e-mail thread of COVID-19 positive cases parent notification and took pictures of outdoor COVID-19 sign out table for parents. LPA did not interview children and parents due to staff statements made during interviews and other information and documents gathered during the course of the investigation.

On 1/26/22, LPA Odom observed staff wearing the face coverings indoors and outdoors, but less than half of the children attending the childcare were not wearing the face coverings while in the classrooms. During the interview with S1, LPA Odom questioned the face coverings policies for the childcare center, S1 provided a copy of the facility COVID-19 policies, in which it stated, during the school day staff will wear face coverings indoors when less than 6 feet from the child. The policy further stated staff are not required to wear face coverings while outside. Children do not have to wear a face covering unless the parent wants them to (As stated in policy “if this is the case, please let one of the teachers know that you want your child to wear a face covering”). S1 stated, they give the parents the option to have the children wear them or not because many of the parents are very adamant in having their children not wearing the face coverings. S1 did not disclose any staff or children having a face coverings exemption. LPA Odom discussed COVID-19 positive cases in the childcare with S1. S1 stated, on 1/9/22 there were 2 positive cases, on 1/10/22 there was 1 positive case, on 1/13/22 there was 1 positive case, on 1/14/22 there was 1 positive case, on 1/15/22 there was 1 positive case, on 1/17/22 there was 3 positive cases, on 1/18/22 there was 2 positive cases, on 1/19/22 there was 1 positive and on 1/23/22 there was 1 positive case for a total of 13 COVID-19 positive cases. S1 disclosed they did not report the initial positive cases to Community Care Licensing (CCL) and Department of Public Health (DPH) until 1/18/22 when DPH contacted S1 regarding COVID-19 outbreak at the childcare center. S1 stated, they did notify via e-mail to the parents about the positive COVID-19 cases in the childcare but did not realize they had to report the COVID-19 positive cases to DPH and CCL.
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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20220118155335

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: LIGHT OF CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300603211
	VISIT DATE: 03/09/2022

NARRATIVE

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During the investigation, 2 staff members were interviewed on 01/26/22. Both staff members disclosed that not all the children wear face coverings indoors, and face covering are optional, and parents have the option to bring face coverings for the children. Staff #2 (S2) stated, S1 does not enforce face coverings for staff members, and throughout the day the staff will remove their face coverings. Staff #3 (S3) stated, they usually wear their face covering but if they remove their face coverings they are standing away from the child.

Based on LPA facility inspection, observations, interviews conducted with complainant party, director, 2 staff, COVID-19 policies, records reviewed, and pictures taken by LPA, it has been determined that the staff and children in care are not wearing face coverings in the childcare center and COVID-19 positive cases were not timely reported to CCL and DPH. Therefore, the preponderance of evidence standard has been met, therefore the above allegation are found to be Substantiated. California Code of Regulations, Title 22, 101223(a)(2) Personal Rights, Health and Safety Code section 1596.885(c) Conduct Inimical for Child Care, and Reporting Requirements 101212(d)(1)(C) is being cited on the attached LIC9099D.

This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Exit interview was conducted with Staff Brenda Ruiz. Notice of Site Visit was posted during the visit. Staff 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. Staff 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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 06-CC-20220118155335

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: LIGHT OF CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300603211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/09/2022 Section Cited CCR 101223(a)(2)	1 2 3 4 5 6 7	101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: On 01/26/2022, facility director did not	1 2 3 4 5 6 7	Staff stated, on 1/30/22 Director sent out an e-mail to all the parents and staff regarding face covering requirements according to DPH. Director also spoke with staff regarding face covering for staff and children indoors. Staff placed a face in each chiild's cubby for the children to wear indoors. LPA Odom observed staff wearing face coverings.
	8 9 10 11 12 13 14	ensure the personal rights of children in care in that the facility staff and children did not wear face coverings indoors as required by the State Public Health Officer Order dated 6/11/21, requiring compliance with CDPH Guidance for the Use of Face Coverings, and the Cal/OSHA COVID-19 Prevention Emergency Temporary Standards (ETS). cont.	8 9 10 11 12 13 14	Continuation from Citation: An exemption to the Order requiring face coverings did not apply. This poses an immediate Health and Safety risk to children in care.
Type A 03/09/2022 Section Cited HSC 1596.885(c)	1 2 3 4 5 6 7	1596.885(c) The department... issued under this act upon any of the following grounds and in the manner provided in this act: (c) Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Staff stated, on 1/30/22 Director sent out an e-mail to all the parents and staff regarding face covering requirements according to DPH. Director also spoke with staff regarding face covering for staff and children indoors. Staff placed a face in each chiild's cubby for the children to wear indoors. LPA Odom observed staff wearing face coverings.
	8 9 10 11 12 13 14	On 01/26/2022, facility director engaged in conduct inimical to the health, welfare, and safety of the children in care, in that the facility staff and children did not wear face coverings indoors as required by the State Public Health Officer Order dated 6/11/21, requiring compliance with CDPH Guidance for the Use of Face Coverings, (continue to next page)	8 9 10 11 12 13 14	Continuation from Citation: and the Cal/OSHA COVID-19 Prevention Emergency Temporary Standards (ETS). An exemption to the Order requiring face coverings did not apply. This poses an immediate Health and Safety risk to children in care.

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20220118155335

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: LIGHT OF CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300603211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2022 Section Cited CCR 101212(d)(1)(C)	1 2 3 4 5 6 7	Reporting Requirements 101212(d)(1)(C ): (d)Upon the occurrence, during the operation...(d)(1) below, a report shall be made to the Dept by telephone…within the... next working day... written report …within seven days following occurrence… (1) Events reported shall include the following…(C)Any unusual incident or child absence that threatens...	1 2 3 4 5 6 7	Staff stated, they have not had anymore COVID-19 positive cases since 1/23/22. Director will submit a written statement indicating that in the future they understand that a positive COVID-19 case needs to be reported to CCL and DPH within 24 hours over the phone and 7 days for written UIR. Submit statement to licesing by 3/11/22.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records reviewed S1 failed to report 13 COVID-19 positive cases to Community Care Licensing and Department of Public Health. This poses a potential Health and 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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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