300614040-6-26-2019-06-CC-JMHN-BDHUWL-20190626155656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300614040
Report Date: 06/26/2019
Date Signed: 06/26/2019 03:57:11 PM

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:	CHRIST LUTHERAN CHILD CARE CENTER		FACILITY NUMBER:	300614040
ADMINISTRATOR:	GOZZA, ANJA		FACILITY TYPE:	840
ADDRESS:	2715 E. LA VETA		TELEPHONE:	(714) 532-2268
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	20	CENSUS: 6	DATE:	06/26/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Anja Gozza		TIME 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), Han and Licensing Program Manager (LPM), Hanson conducted an unannounced annual/random inspection of the facility on today's date. LPA Han toured the facility with the director, Anja Gozzo inside and outside. Census was taken in individual classrooms. The overall census observed was 1 director and 6 school age children in room #3. 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 6:30 am- 6:00 pm, Mon-Fri. The hand soap which could pose a danger to children was placed on the children’s bathroom sink. It is accessible by children. Poisons/Hazardous Items are not kept on the premises. Food is prepared on site; snacks are provided. Food prep areas appear clean and sanitary. Food is properly stored. On site kitchen is free from hazards. Snack menu was not available to view at least one week advance. The snack menu for today’s date is veggie sticks, fruit, cheese, and crackers, but the staff stated she offered salamis and crackers for today’s morning snack. The toys, floors, desks and other equipment appeared clean. There is drinking water available to children both indoors and outdoors. The children's bathrooms are clean and sanitary. The facility has conducted an emergency drill within the past six months. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground was completely fenced. The part of playground brick fence is not four feet high. LPA measured and confirmed it is 3 feet and 6 inches tall. The playground equipment including swing seats, bench, and playground surface are not clean for children to play. The handball wall is also needs to be repainted to prevent children from injury. The right corner fence needs to be repaired. (see attached LIC 813 for all playground hazardous items). The playground equipment appeared in safe condition. There is sufficient cushioning underneath climbing structures and play equipment to absorb falls. Sign in/out procedure was reviewed for compliance. Couple of sign in/out did not have full signatures. During today's visit staffing ratios were being met. At least one staff member present possesses current CPR/First Aid certifications, which expires 10/2020.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2019

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
	VISIT DATE: 06/26/2019

NARRATIVE

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Do not hang any items from the crib or above the crib
Keep all items, including blankets, out of the crib or play yard
Pacifiers may be used as long as they do not have items attached to them
Infants should not be swaddled or have any items covering them while sleeping
The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

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

Documents/Information to be updated and returned to the Licensing Office;
- Personnel Report (LIC 500)
- Emergency Disaster Plan (LIC 610)
- Designation of Administrative Responsibility (LIC 308)
- Administrative Organization (LIC 309)

Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. Appeal Rights and deficiencies were 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

The director was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

Page: 2 of 8

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

Staff Records

1596.8662.(b)(1)… mandated reporter…proof of completion ...January 1, 2018, is a licensed child care provider..shall complete the mandated reporter training provided...renewal mandated reporter training every two years...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of staff#1, the director failed to ensure to have mandated reporter training certificates for staff#1. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will submit staff#2's mandated reporter training certificate by email by due date. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

CCR

101229.1(a)(1)

Children Records

101229.1 (a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.
	Deficient Practice Statement
1 2 3 4	Based on record review, the director failed to ensure to maintain full signaure on sign in and out sheet. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will submit proof of correction (LIC 9098) by due date by email.

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: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

Page: 3 of 8

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238.2(g)

Physical Plant - Outdoor Activity Space

(g) The playground shall be enclosed by a fence to protect children and to keep them in the outdoor activity area. The fence shall be at least four feet high.
	Deficient Practice Statement
1 2 3 4	Based on observation and measurement, the part of playground fence is lower than 4 feet tall. LPA measured and it was 3 feet 6 inches tall. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will add height on existing fence to ensure all playground fence is higher than 4 feet tall. The director will submit proof by email by due date.

Type B

Section Cited

HSC

1596.7995(a)(1)

Staff Records - California Child Day Care Act

(1) Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
	Deficient Practice Statement
1 2 3 4	Based on record review, the director failed to ensure to maintain staff#1's immunization record in the file. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will submit its proof by email by due date. JUNGMI.HAN@DSS.CA.GOV

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: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

Page: 4 of 8

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101227(a)(6)

Food Service

(6) Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the menu is not posted at least one week in advance. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will submit proof of correction (LIC 9098) by due date by email. JUNGMI.HAN@DSS.CA.GOV

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.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238(a)

Physical Plant - Buildings and Grounds

(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the director failed to ensure to keep playground clean, safe, and sanitary at all times. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	Director will clean the playground equipment including swing seats, bench, and playground surface. Director also repaint handball wall and repair the right corner fence that has hole. The director will submit its proof by email by due date. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

CCR

101238(g)

Physical Plant - Buildings and Grounds

(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.
	Deficient Practice Statement
1 2 3 4	Based on observation, the director failed to ensure to keep out of reach of children for hand soap at the children's restroom. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will submit proof of correction (LIC 9098) by due date by email. JUNGMI.HAN@DSS.CA.GOV

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: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
	VISIT DATE: 06/26/2019

NARRATIVE

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Children's and staff files were reviewed for compliance. Staff#1 did not have mandated reporter training certificate, Health screening report (LIC503), TB test result, and required immunization records in staff file. Child#1 did not have any documents to review upon request.

The facility does not provide Incident Medical Services.
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 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

Based on LPAs observations, record reviews, and interviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101229(a)(1), 101238(a), 101238.2(g), 101227(a)(6), 101216(g)(1), 101221(a) and Health and Safety 1596.8662(b)(1), 1596.7995(a)(1). Please refer to attached 809D for documentation of deficiencies.

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
Always place infants on their backs for sleeping
Use only a tight-fitting sheet on the crib or play yard mattress

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: CHRIST LUTHERAN CHILD CARE CENTER	FACILITY NUMBER: 300614040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(g)(1)

Staff Records - Personnel Requirements

(g) All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks. (1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
	Deficient Practice Statement
1 2 3 4	Based on record review, the director failed to ensure to maintaing staff#1's Health Screening Report (LIC503) and TB test result in the staff file. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will sbumit proof by email by due date. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

CCR

101221(a)

Children Records - Child's Records

(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.
	Deficient Practice Statement
1 2 3 4	Based on record review, the director failed to ensure to maintain child#1's file in children's file. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/24/2019
	Plan of Correction
1 2 3 4	The director will submit child#1's required file by email by due date.

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: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019

LIC809 (FAS) - (06/04)

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