300606475-1-31-2020-06-CC-KDEI-BLCPV3-20200131103829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300606475
Report Date: 01/31/2020
Date Signed: 01/31/2020 10:38:41 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:	KING OF KINGS LUTHERAN CHURCH		FACILITY NUMBER:	300606475
ADMINISTRATOR:	DAWN GOETZ		FACILITY TYPE:	850
ADDRESS:	13431 NEWHOPE STREET		TELEPHONE:	(714) 530-2152
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	20	CENSUS: 7	DATE:	01/31/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Dawn Goetz		TIME COMPLETED:	10:45 AM

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), Ketki Desai conducted an unannounced annual/random inspection of the facility on today's date. LPA Ketki Desai toured the facility with the director, (Dawn Goetz) inside and outside. Census was taken in individual classroom. The overall census observed was 1 preschool staff and 7 preschool children in the assigned classroom. 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 8:00 am- 5:30 PM, Mon-Fri. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. 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. Children bring in their own PM snack and Lunch from home, lunch boxes are stored in their individual cubbies. Center serves AM snacks to the children. The toys, floors, desks and other equipment appeared clean. There is drinking water available to children both indoors and outdoors via Water dispenser and water fountain. The children's bathrooms are clean and sanitary. Children nap during their time (1.15 PM -2.30 PM) and the linens are brought from home. Sleeping mats are provided by the center.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020

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 3

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: KING OF KINGS LUTHERAN CHURCH	FACILITY NUMBER: 300606475
	VISIT DATE: 01/31/2020

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
26
27
28
29
30
31
32

The facility has conducted an emergency drills within the past month ( Fire/ Earthquake and lock down Drills). 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 enough cushioning underneath climbing structures and/or play equipment to absorb falls and has enough shade. Wooden chips are used as a cushioning material under the play structure. Waiver in place for shared play ground
Sign in/out procedure was reviewed for compliance. Children have been signed in and out with legal signatures. During today's visit staffing ratios were being met. At least one staff member present possesses current CPR/First Aid certifications, which expires 08/12/2021.Children's and staff file was reviewed for compliance. Five children's and Administrator file were in compliance. Proof of immunization's against pertussis, influenza (or written declination), and measles for all employees/volunteers was reviewed for compliance with SB 792. Certificates of completion for mandated reporter training was reviewed.

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
Currently there are no children receiving the above Medical services. Medication are stored in a locked cabinet in the storage area.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: KING OF KINGS LUTHERAN CHURCH	FACILITY NUMBER: 300606475
	VISIT DATE: 01/31/2020

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
26
27
28
29
30
31
32

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.

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

Licensee was advised to place a child safety gate across the storage room, making the area inaccessible to children.

Exit interview was conducted. Report reviewed and 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

Notice of Site Visit was posted during the visit. The 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.

All licensing reports are public information and must be made available upon request.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3