304371273-2-9-2022-06-CC-MMAK-CBGSSB-20220209130740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371273
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:07:46 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:	OUR SAVIOR'S LUTHERAN PRESCHOOL		FACILITY NUMBER:	304371273
ADMINISTRATOR:	LUNDBOHM, JOAN		FACILITY TYPE:	830
ADDRESS:	200 AVENIDA SAN PABLO		TELEPHONE:	(949) 492-6165
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92672
CAPACITY:	15	CENSUS: 7	DATE:	02/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Director		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	Page 1 of 3 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an onsite inspection for the purpose of an Annual Inspection. LPA met with director, Joan Lundbohm. The Covid-19 Emergency Response questionnaire was reviewed and answered by the director. LPA and the director toured the facility inside and outside, and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 7 infants and toddlers with 2 staff in rooms 304 and 305. Due to COVID 19 guidelines, LPA observed staff wearing face masks, and were following CDC and Dept of Public Health Guidelines. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. Facility hours are 7am - 6pm., 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. 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. During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Bottles and containers for infants and toddlers were inspected and were labeled. Floors, equipment, and furniture were clean and observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary. Children's bedding was discussed to be washed on a daily basis. The facility has conducted an emergency drill within the past six months and keeps documentation of drills. The facility has a at least one working smoke detector, one working carbon monoxide detector. Facility meets all the posting requirements. Continued on page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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: OUR SAVIOR'S LUTHERAN PRESCHOOL	FACILITY NUMBER: 304371273
	VISIT DATE: 02/09/2022

NARRATIVE

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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 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.
Two staff files were reviewed for staff present during the facility inspection on this date. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for all staff were reviewed. 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 least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications.
Ten children's records were reviewed, and there was a separate, complete and current record for each child. This facility provides Incidental Medical Services. 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.htmThe 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 facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF

Continued on page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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: OUR SAVIOR'S LUTHERAN PRESCHOOL	FACILITY NUMBER: 304371273
	VISIT DATE: 02/09/2022

NARRATIVE

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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.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director, Joan Lundbohm.

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.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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