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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830314
Report Date: 12/04/2019
Date Signed: 12/04/2019 12:06:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:PRINCE OF PEACE LUTHERAN PRESCHOOLFACILITY NUMBER:
334830314
ADMINISTRATOR:CAROLYN WILLIAMSFACILITY TYPE:
850
ADDRESS:701 N. SANDERSON AVENUETELEPHONE:
(951) 925-9798
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:82CENSUS: DATE:
12/04/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rev. Dr. Eugene SmithTIME COMPLETED:
12:15 PM
NARRATIVE
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On 12/04/2019 at 8:50 AM, Licensing Program Analyst Susan Brewer, arrived at the facility for the purpose of conducting a Case Management Visit, following a Complaint Investigation that took place on 11/22/2019 and 11/25/2019. LPA S.Brewer, identified herself and the purpose of the visit, was greeted by the Rev. Dr. Eugene Smith of Prince of Peace Lutheran Church and also a member of the board that governs the Prince of Peace Lutheran Pre-School. LPA was granted entry into the facility and a census was taken.

On 11/22/2019 and again on 11/25/2019, LPA S.Brewer, conducted confidential interviews and reviewed children and staff records as part of the complaint investigation. LPA also interviewed the Site Director Lilah Wheeler. Based on the information gathered by the LPA, it was determined that Site Director failed to ensure that an unusual incident had occurred on 11/04/2019, between a staff, other staff members and a day care child, was to be documented in the child's file or the staff files. The Director Lilah Wheeler, indicated that she thought that the incident had been reported by another staff, however, the Director could not confirm the staff name.

A Type B Citation was issued due to the Site Director, failing to report the Unusual Incident that took place on 11/04/2019, to Community Care Licensing as required by Title 22 regulation 101212 Reporting Requirements: 101212 (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1), a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Susan BrewerTELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PRINCE OF PEACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 334830314
VISIT DATE: 12/04/2019
NARRATIVE
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An exit interview was conducted with facility Rev. Dr. Eugene Smith and Site Director Lilah Wheeler and Appeal rights discussed.

A NOTICE OF SITE VISIT WAS ISSUED AND IS TO BE POSTED IN A PROMINENT LOCATION AT THE FACILITY FOR THE NEXT 30 DAYS.

See LIC809D for cited deficiencies regarding documentation required at the facility.

A copy of this report was reviewed and provided to the facility Rev. Dr. Eugene Smith and Site Director Lilah Wheeler and the signatures on the report acknowledging receipt.
SUPERVISOR'S NAME: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Susan BrewerTELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: PRINCE OF PEACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 334830314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2019
Section Cited

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101212 (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1), a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hour.
This requirement was not met as evidenced by:
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The licensing Site Director Lilah Wheeler, failed to report an unusual incident on 11/04/2019, to Community Care Licensing on the LIC624 as required by Title 22 Standards, after being informed by a staff member & having knowledge of the incident, which poses a potential risk to day care children.
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A copy of board minutes addressing the required guidelines and protocols, for timely documentation & steps to follow-through with reporting standards will be submitted by Rev. Dr. Eugene Smith, by fax or mail, to CCL Riverside, CA by 11/18/2019.

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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: Telma SandovalTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Susan BrewerTELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2019
LIC809 (FAS) - (06/04)
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