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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340320556
Report Date: 07/18/2023
Date Signed: 07/18/2023 05:41:32 PM


Document Has Been Signed on 07/18/2023 05:41 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER:
340320556
ADMINISTRATOR:DORIS DAHLEFACILITY TYPE:
850
ADDRESS:8701 ELK GROVE-FLORIN ROADTELEPHONE:
(916) 689-3050
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:60CENSUS: 9DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Hannah StringerTIME COMPLETED:
06:00 PM
NARRATIVE
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On July 18, 2023 Licensing Program Analyst (LPA) Jennie Tedlos and Licensing Program Manager (LPM) Bettina Engelman conducted a case management inspection at the facility and met with Director, Hannah Stringer. LPA observed (9) nine children supervised by a teacher.

LPA toured the facility and conducted record reviews. Director stated that there was an incident in October 2022 where a child was left on the playground unsupervised by staff and the incident was not reported to licensing.

Based on today's observations, a Title 22 Deficiency has been cited on the attached LIC 8099D.

Exit interview conducted at which time the report was reviewed with Director, Hannah Stringer. A Notice of Site Visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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 2


Document Has Been Signed on 07/18/2023 05:41 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ST. PETER'S LUTHERAN SCHOOL
FACILITY NUMBER: 340320556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
101212(d)

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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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.
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Director shall submit an Unusual Incident Report to LPA. LPA provided LIC 624 to Director. Director acknowleged the regulation to report Unusual Incidents to licensing.
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This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision in October 2022 and the incident was not reported to licensing.
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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: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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