300606475-5-13-2025-06-CC-VTRH-DGMUAR-20250513152510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300606475
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:25:22 PM

Document Has Been Signed on 05/13/2025 03:25 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:	KING OF KINGS LUTHERAN CHURCH		FACILITY NUMBER:	300606475
ADMINISTRATOR/ DIRECTOR:	BUTH, REBECCA		FACILITY TYPE:	850
ADDRESS:	13431 NEWHOPE STREET		TELEPHONE:	(714) 530-2152
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 20	CENSUS: 7	DATE:	05/13/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Buth, Rebecca (Director)		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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On 5/13/2025, Licensing Program Analyst (LPA) Vivian Trinh conducted an on site inspection for the purpose of an Annual Inspection. LPA and the Director Buth, Rececca tour the facility inside and outside, and the floor and yard plan (LIC 999) were verified. The overall census observed was one (1) preschool staff and seven (7) preschool-age children were napping. During the inspection, it was determined that the facility is operating within its licensed capacity and is compliant with staffing ratios. Facility hours are 7:30 a.m.- 3:30 p.m., Monday through Friday. A review of the Facility Personnel Report Summary on this date 5/13/2025 indicates all facility staffs or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
CRIMINAL RECORD CLEARANCE: A review of the Facility Personnel Report Summary on this date 05/13/2025. The Director understands that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption or transfer their existing clearance or exemption prior to the initial presence in a licensed childcare facility. Violation of this requirement will result in a citation of a deficiency and civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred dollars ($100) per violation per day for a maximum of thirty (30) days in accordance with Section 1596.871 of the Health and Safety Code.

INDOOR INSPECTION. The LPA inspected the indoor areas and areas accessible to children at the time of the visit. The facility was equipped with working carbon monoxide and smoke detectors, working telephone service, and at least one fire extinguisher that meets statutory and State Fire Marshall standards. A record review shows that the last drill was documented on January 23, 2025.

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Nguyen K Tran	TELEPHONE: (714) 658-6048
Vivian Trinh	TELEPHONE: (949) 466-1624
	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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: KING OF KINGS LUTHERAN CHURCH	FACILITY NUMBER: 300606475
	VISIT DATE: 05/13/2025

NARRATIVE

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The director stated that there are no firearms and/or other dangerous weapons in the facility; none were observed during the inspection. Children nap on mats, and bedding is stored individually and is taken home weekly to be washed by parents. Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available were inaccessible to children in care. No poisons or other items that could pose a danger to children were observed during the inspection. The facility provides age-appropriate toys, play equipment, and materials for the children served.

ON-SITE FOOD PREPARATION: The center only provided morning snack, and afternoon snacks to children. At the time of inspection, food prep areas were clean and sanitary, and food was properly stored. Drinking water is available to children in care. Drinking water is available to children indoors and children bring their own water bottles from home with child’s name on it, and each classroom has a mini bottle water. The LPA observed that the facility’s floors, equipment, furniture, and children’s bathrooms were clean, in good repair, and free of sharp edges. The facility meets all posting requirements.

OUTDOOR INSPECTION. The outdoor activity space was inspected for compliance. The playground is enclosed by a fence at least four feet in height and is in good repair. The surface of the outdoor activity space is maintained and free of hazards. The cushioning material around outdoor play equipment and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by water bottles. The outdoor equipment and toys are in good repair and free of sharp edges. There are no bodies of water present at the facility. The inspected outdoor facility grounds are safe, sanitary and in good repair.

PERSONNEL RECORDS. Staff files were reviewed for staff present during the facility inspection on this date, 1 out of 1 staff file was reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a child day care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis and measles for staff members was reviewed and within compliance. 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. At 1:15 pm, during staff file review and interview, Staff 1 (S1) did not have their mandated reporter training certificate expired 4/15/2025. At least one staff member present has current EMSA-approved Pediatric CPR/First Aid 7/31/2025 certifications.

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SUPERVISOR'S NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian Trinh	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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: KING OF KINGS LUTHERAN CHURCH	FACILITY NUMBER: 300606475
	VISIT DATE: 05/13/2025

NARRATIVE

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CHILDREN’S RECORDS: Children's records were reviewed for compliance present during the facility inspection on this date, 5 out of 5 children files were reviewed Each child has a separate, complete, and current record. The person who signs the child in and out uses their full legal signature and records the time of the day. Transportation is NOT offered to children.

The Incidental Medical Services (IMS) policy was discussed. A link to PIN 22-02-CCP was provided here: PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The Director was informed that Licensing Quarterly Updates are available at www.cdss.ca.gov Director may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.cdss.ca.gov

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

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

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SUPERVISOR'S NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian Trinh	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: KING OF KINGS LUTHERAN CHURCH	FACILITY NUMBER: 300606475
	VISIT DATE: 05/13/2025

NARRATIVE

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LEAD TESTING: 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. The child care center is located in a building that was constructed in 2017. Director submitted LIC 9275 and LIC 9276. Water Board website shows no lead exceedance.

Based on LPA record review, the facility was not in compliance and is being cited in accordance to the Health and Safety Code; for the following violations: Administration of Child Day Care Licensing HSC 1597.622(b)(1), on the attached LIC 809D.

Appeal Rights and deficiencies were discussed. The 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. A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and the report was reviewed with the director.

End of the Report.

SUPERVISOR'S NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian Trinh	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2025 03:25 PM - It Cannot Be Edited

Created By: Vivian Trinh On 05/13/2025 at 02:53 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KING OF KINGS LUTHERAN CHURCH	FACILITY NUMBER: 300606475
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. 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. At 1:15 pm, during staff file review and interview, Staff 1 (S1) did not have their mandated reporter training certificate expired 4/15/2025, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	The Director stated will submit the current Mandated Reporter Training from Staff 1 to LPA by due date.

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
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (714) 658-6048

	Vivian Trinh
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (949) 466-1624

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

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