300606158-5-16-2025-06-CC-DTHN-DGQTGZ-20250516144357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300606158
Report Date: 05/16/2025
Date Signed: 05/16/2025 02:44:24 PM

Document Has Been Signed on 05/16/2025 02:44 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	ST. JOHN'S LAMB'S LOT PRESCHOOL		FACILITY NUMBER:	300606158
ADMINISTRATOR/ DIRECTOR:	FRAZIER, TRISHA		FACILITY TYPE:	850
ADDRESS:	151 S. CENTER		TELEPHONE:	(714) 288-4409
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY: 104	TOTAL ENROLLED CHILDREN: 115	CENSUS: 78	DATE:	05/16/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Trisha Frazier		TIME VISIT/ INSPECTION COMPLETED:	03:00 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), Thompson conducted an on-site visit for the purpose of an annual Inspection. LPA and Director Trisha Frazier toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken in each individual classroom. LPA observed a total of 78 preschool age children with 10 staff during nap time. Facility hours are Monday through Friday, 7:00 AM to 6:00 PM. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates not all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. While touring the facility, LPA observed Gwendolyn Grant Stanga and Alisa Marie Holte caring for children in care during nap time. During staff file reviews, LPA observed Gwendolyn Grant Stanga and Alisa Marie Holte were not associated to the facility. Gwendolyn and Alisa submitted fingerprints and were both sent Action Required letters from CDSS and their determination status closed due to incomplete applications. Director confirm, Gwendolyn has been present at the center since 2019 and Alisa has been present since 2023. Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. Continue to page 2

Nguyen K Tran	TELEPHONE: (714) 658-6048
Dean Thompson	TELEPHONE: (714) 287-0708
	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ST. JOHN'S LAMB'S LOT PRESCHOOL	FACILITY NUMBER: 300606158
	VISIT DATE: 05/16/2025

NARRATIVE

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LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications, or hazardous items). There is filtered drinking water available indoors for children in care. Children also bring their water bottles from home. The children's bathrooms are clean and sanitary. Children nap on cots if they choose to sleep, and bedding is washed weekly at the facility.

The facility provides snacks and lunch can be purchased through the choice lunch program. Menus were posted where the can be viewed by parents.

The facility has conducted an emergency drill within the past six months, last drill conducted on 5/14/2025. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material rubber mats commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is by sports bottles. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Staff files were reviewed for five staff present during the inspection. Health screening and immunization records as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a day-care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization for staff were reviewed and within compliance.

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SUPERVISOR'S NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ST. JOHN'S LAMB'S LOT PRESCHOOL	FACILITY NUMBER: 300606158
	VISIT DATE: 05/16/2025

NARRATIVE

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Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Teacher present possesses current American Red Cross approved child CPR/First Aid certifications, which expires 8/14/2025.

Children's records were reviewed, and there was a separate, complete, and current record for each child. A random sample of five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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 PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

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SUPERVISOR'S NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ST. JOHN'S LAMB'S LOT PRESCHOOL	FACILITY NUMBER: 300606158
	VISIT DATE: 05/16/2025

NARRATIVE

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Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

In the areas that were evaluated, one Staff Records - Type A: 1596.871(c)(1)(A) deficiency was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. See LIC 809D page for deficiency.

LPA Thompson informed Director Trisha Frazier that this report dated 05/16/2025, document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Thompson informed the Director Trisha Frazier to provide a copy of this licensing report dated 05/16/2025, that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Director Trisha Frazier

Appeal Rights discussed. Director was provided a copy of their appeal rights (LIC 9058) 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..

SUPERVISOR'S NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2025 02:44 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ST. JOHN'S LAMB'S LOT PRESCHOOL	FACILITY NUMBER: 300606158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. While touring the facility, LPA observed Gwendolyn Grant Stanga and Alisa Marie Holte caring for children in care during nap time. During staff file reviews, LPA observed Gwendolyn Grant Stanga and Alisa Marie Holte were not associated to the facility. Gwendolyn and Alisa submitted fingerprints and were both sent Action Required letters from CDSS and their determination status closed due to incomplete applications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2025
	Plan of Correction
1 2 3 4	Director stated both Gwendolyn Grant Stanga and Alisa Marie Holte wil be sent to go resubmit fingerprints.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nguyen K Tran	TELEPHONE: (714) 658-6048
Dean Thompson	TELEPHONE: (714) 287-0708
	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

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