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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313614186
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:00:39 PM


Document Has Been Signed on 04/12/2022 03:00 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:HOLY CROSS LUTHERAN PRESCHOOLFACILITY NUMBER:
313614186
ADMINISTRATOR:WILLIAMS, OCTAVIAFACILITY TYPE:
850
ADDRESS:4701 GROVE STREETTELEPHONE:
(916) 624-2123
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:126CENSUS: 52DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Octavia WilliamsTIME COMPLETED:
03:15 PM
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All times on this report are approximations. At 12:45 p.m. on Tuesday, April 12, 2022, Licensing Program Analyst (LPA) Amanda Blesi met with Director, Octavia Williams, for the purpose of an unannounced 1 year required inspection. Director guided LPA on a tour of the facility, at which time a census of 47 preschool and 5 school age children were observed.

A health and safety inspection was conducted in the classrooms, restrooms, food service areas, and outdoor play areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Medications are stored, inaccessible to children. Director stated there are no poisons on the premises. Furniture and equipment are in good condition, and toileting facilities are in sanitary, and operating condition. Bins for solid waste in the kitchen have tight fitting lids. The floors appeared clean throughout the facility.There are functional water fountains indoors and outdoors. Children also have labeled water bottles. Playground equipment and surfaces are free of loose or sharp parts. LPA observed wood chip cushioning beneath the play structure. Outdoor shade is provided by trees and awnings. There are no firearms or bodies of water on the premises. LPA observed a functional carbon monoxide detector.LPA reviewed staff files. At least one staff member present today has current Pediatric CPR and First Aid certification. LPA observed immunization records and documentation of the educational background, training, and/or experience. LPA observed updated AB 1207 Mandated Reporter training certificates. Director was advised that Mandated Reporter training must be renewed every two years and can be renewed at www.mandatedreporterca.com. Facility representative 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.(Report continues on 809-C)

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HOLY CROSS LUTHERAN PRESCHOOL
FACILITY NUMBER: 313614186
VISIT DATE: 04/12/2022
NARRATIVE
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This facility provides Incidental Medical Services – IMS. 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 Center Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 513-0301 (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.htLLPA discussed Assembly Bill 2370, which will require licensed Child Care facilities to test their water for excessive amounts of lead. Testing will be required beginning January 1st, 2020 to January 1st, 2023 and must be conducted every five years from initial testing.

Title 22 Deficiency has been cited on the attached LIC 809-D. LPA Amanda Blesi informed facility representative Octavia Williams that this report dated 4/12/22 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Amanda Blesi informed facility representative to provide a copy of this licensing report dated 4/12/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Appeal Rights given.

Exit interview conducted and report was reviewed with the facility representative Octavia Williams. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/12/2022 03:00 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: HOLY CROSS LUTHERAN PRESCHOOL
FACILITY NUMBER: 313614186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
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, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when Staff #1 fingerprint clearance was not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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By POC date of 4/13/22, director shall submit proof to LPA that staff #1 is associated to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/12/2022 03:00 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: HOLY CROSS LUTHERAN PRESCHOOL
FACILITY NUMBER: 313614186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff #1 did not have proof of MMR and Tdap which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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By plan of correction date 4/26/22, director shall submit proof of immunization for MMR and Tdap for staff #1.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4