300605642-11-19-2019-06-CC-MMAK-BJ3R87-20191119114729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300605642
Report Date: 11/19/2019
Date Signed: 11/19/2019 11:47:33 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:	LUTHERAN CHURCH OF THE CROSS		FACILITY NUMBER:	300605642
ADMINISTRATOR:	THEVENY, TONYA		FACILITY TYPE:	850
ADDRESS:	24231 EL TORO ROAD		TELEPHONE:	(949) 581-8115
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	48	CENSUS: 36	DATE:	11/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Office Administrator and director		TIME COMPLETED:	12:15 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	Page 1 An unannounced inspection was conducted today by Licensing Program Analysts (LPA) Mahnaz (Nancy) Malek. LPA met with office administrator, Jennifer Uhlman. The director, Tonya Theveny was with the children in the Chapel. Children came back to their classrooms with their children. Census was taken. There were a total of 36 preschool children with 6 staff including the director in three classrooms and on the playground. Classrooms A, B, C, and D were inspected. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility was reviewed to ensure compliance with license conditions and limitations, staffing and ratios, inaccessibility to poisons, medication, and hazardous items that can pose a danger to children. Equipment and furniture was inspected to ensure it's in good condition, free of sharp, loose or pointed parts. Toilets and sinks were inspected to ensure they are safe and in a sanitary operating condition, floors were inspected for safety and cleanliness. The food preparation area was inspected for cleanliness, free of rodents/vermin, appropriate storage of food, and verification of posted menus. There are no weapons, firearms or bodies of water observed in the facility. The playground was inspected for safety, good condition of equipment, including appropriate cushioning material around and under high climbing equipment.(Sand). Staff's files were reviewed for education verification, CPR/First Aid, and new immunization requirements for (MMR, Pertussis, and Flu vaccines). A sample of children's files were reviewed for completeness of admission agreement, verification of sign in/out including time the child was signed in/out by authorized representative as well as verification of representatives full legal signature. continues on page 2

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
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: LUTHERAN CHURCH OF THE CROSS	FACILITY NUMBER: 300605642
	VISIT DATE: 11/19/2019

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The facility has sent the update plan of operation for providing IMS to our office. 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

The Notice of Site Visit was posted. Facility representative 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. The licensee was provided a copy of their appeal right (LIC 9058 1/16) 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. First level appeal is to Regional Manager, address is above on the report. The facility representative was informed that they can refer to our Department website at www.ccld.ca.gov for obtaining the quarterly updates.

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

A copy of child care provider's guide to safe sleep pamphlet and a copy of Never Ever Shake a Baby pamphlet with the website www.dontshake.org were given to the facility representative on the previous inspection. An updated pamphlet regarding safe sleep regulations in childcare and a pamphlet for lead poisoning facts were given to the director today.
The Mandated Reporter Training Certificates for staff were reviewed.

In the areas that were evaluated, the facility was in compliance of the California Code of Regulations, Title 22, Division 12. No deficiencies were cited.

This report ends here.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
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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