304371197-7-5-2023-06-CC-CODM-CTFVYY-20230705165154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371197
Report Date: 07/05/2023
Date Signed: 07/05/2023 04:52:05 PM

Document Has Been Signed on 07/05/2023 04:52 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	KING OF GLORY LUTHERAN CHURCH & PRESCHOOL		FACILITY NUMBER:	304371197
ADMINISTRATOR:	DANIELS, STEPHANIE		FACILITY TYPE:	830
ADDRESS:	10280 SLATER AVENUE		TELEPHONE:	(714) 968-5865
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	12	CENSUS: 3	DATE:	07/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Yazmin Hernandez - Lead teacher		TIME COMPLETED:	05:05 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), Carmen Odom conducted an onsite inspection for the purpose of an Annual Random. LPA met with Lead teacher Yazmin Hernandez. Lead teacher stated Director wet home sick. Staff took LPA on a tour of the facility inside and outside the floor and yard plan (LIC 999). Census was taken in Room A & D. The overall census observed was 2 infant staff and 3 infant children; 1 infant was awake and 2 napping. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Director arrived at the facility at 3:45pm. Facility hours are 7:00a.m.- 6:00p.m., Monday through Friday. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, items which could pose a danger to children (cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Infant food is provided by families and served on site. Bottles and food containers brought from home are properly labeled with name and date. Food prep areas were clean and sanitary. Food is properly stored. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by water bottles with the child’s name on it. Infants are not potty trained in the infant center. Infant napping area had individual cribs with tight fitted sheets, no blankets or objects were observed inside or hanging from the cribs. The furniture, equipment and toys were age appropriate for infants. A baby walker is not allowed on the premises of a childcare center. There is sufficient napping equipment. The changing table is within arm’s reach of a sink and appears clean and sanitary. Infant changing tables have a padded surface no less that one inch thick and are covered by washable vinyl/plastic. Infant changing tables have raised sides at least three inches high. Continue to page 2

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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: KING OF GLORY LUTHERAN CHURCH & PRESCHOOL	FACILITY NUMBER: 304371197
	VISIT DATE: 07/05/2023

NARRATIVE

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Trash receptacles containing solid waste have tight fitting lids. Firearms and other weapons are not allowed or stored on the premises. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement.

There is a separate infant playground physically separate from the other age groups. 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. Drinking water in the outdoor activity space is provided by water 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. Facility conducted a water lead test.

Staff files were reviewed for staff present during the facility inspection on this date, 5 staff files were reviewed. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for infant staff were 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, staff files reviewed were within compliance. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 3/2025. Infant teacher qualification was reviewed for staff and within compliance.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 5 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 (LIC701 and LIC702). LPA reviewed LIC 9227 Individual Infant Sleeping Plan in children’s files and napping log for all infants up to 24 months. At 3:45pm while reviewing children’s files 2 out 5 children’s files were missing immunization records. 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.
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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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: KING OF GLORY LUTHERAN CHURCH & PRESCHOOL	FACILITY NUMBER: 304371197
	VISIT DATE: 07/05/2023

NARRATIVE

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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

The director was informed that Licensing Quarterly Updates are available at www.ccld.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.ccld.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 director 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. Facility Director signed up to take the lead training 7/8/21.

Licensee was reminded 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 initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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: KING OF GLORY LUTHERAN CHURCH & PRESCHOOL	FACILITY NUMBER: 304371197
	VISIT DATE: 07/05/2023

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Based on LPAs observations, record reviews and interviews the following violation was observed is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101220.1(g) Immunizations, is being cited on the attached LIC 809D.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

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

Appeal Rights and deficiencies 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.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/05/2023 04:52 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
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: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101220.1(g)

Immunizations

(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, At 3:45pm while reviewing children’s files 2 out 5 children’s files were missing immunization records. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2023
	Plan of Correction
1 2 3 4	Director stated they will communicate with both children's parents to obtain a copy of the children't immunization records. Director will submit a copy of the 2 children's immunizations records to licensing by the 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.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

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