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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371197
Report Date: 09/21/2022
Date Signed: 09/27/2022 09:50:33 AM


Document Has Been Signed on 09/27/2022 09:50 AM - It Cannot Be Edited

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 GLORY LUTHERAN CHURCH & PRESCHOOLFACILITY NUMBER:
304371197
ADMINISTRATOR:KELLY RAMIREZFACILITY TYPE:
830
ADDRESS:10280 SLATER AVENUETELEPHONE:
(714) 968-5865
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:12CENSUS: 9DATE:
09/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:14 PM
MET WITH:Stephanie Daniels, DirectorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 09/21/2022, Licensing Program Analyst (LPA) Romy Castanon and Licensing Program Manager (LPM) Rina Lopez conducted a Case Management due to deficiencies observed during today's inspection. LPA Castanon and LPM Lopez met with Director Stephanie Daniels. A tour of the infant classroom was conducted, and a census was taken. Observed at the time of the visit was a total of 9 infants and 4 staff. A copy of the children's sign in sign out was provided during inspection, one child was not signed in today.

A review of the Facility Personnel Report Summary on 09/21/2022 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions, with the exception of Sarah Landgren (start date: 7/18/2022), Avery Eley (start date: 7/18/2022) and Stephanie Daniels (start date: 7/1/2022), and Theresa Davis who's fingerprints show as "Pending". LPA informed director three out of the four staff above were not associated to the facility. Director was able to associate herself, Sarah, and Avery today. Per review of Guardian's record, all except for Theresa are associated as of today. Theresa Davis fingerprints are still pending. A civil penalty of $2,000.00 is being assessed today.

Based on LPA’s interview conducted with Director, the facility is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101170(e)(2) Criminal Background Clearance for four staff not being associated to the facility.

Appeal Rights were discussed. The facility representative 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 conducted and report was reviewed with Director Stephanie Daniels. (End of Report)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M CastanonTELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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Document Has Been Signed on 09/27/2022 09:50 AM - 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: KING OF GLORY LUTHERAN CHURCH & PRESCHOOL
FACILITY NUMBER: 304371197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2022
Section Cited

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101170(e)(2) Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working...in a licensed facility (2)Request a transfer of a criminal record clearance...This requirement is not met as evidenced by:
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A review of the Facility Personnel Report Summary on 09/21/2022 indicates three facility staff were not associated to the infant license and one associated staff status is "PENDING". This is an immediate risk to the health and safety of children in care.
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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: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M CastanonTELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2022 09:50 AM - 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: KING OF GLORY LUTHERAN CHURCH & PRESCHOOL
FACILITY NUMBER: 304371197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2022
Section Cited

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101229.1(a)(1)(b)-Sign In and Sign Out (a)In addition to the sign-in procedure... (1)The person who signs the child in/out...use signature and shall record the time of day. (b)The person who brings...removes the child from, the center shall sign the child in/out. This requirement is not met as evidenced by:
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Based on observation and interview with Director, one child was missing signed in/out with full legal signatures. This is an potential risk to the health and safety of children in care.
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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: Rina LopezTELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Romelia M CastanonTELEPHONE: (714) 746-8565
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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