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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340320556
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:27:46 PM


Document Has Been Signed on 09/07/2023 03:27 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: 41DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Doris DahleTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jennie Tedlos met with Director, Doris Dahle, for the purpose of an unannounced annual inspection. Facility hours of operation are M-F, 7:00AM-6:00PM. There were 41 children present during today's inspection. LPA reviewed the sign in/out book and observed that the children are properly signed in.

LPA toured the facility inside and out. LPA observed that hazardous items (disinfectants, cleaning solutions etc.) were inaccessible to children in care. LPA reviewed staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. LPA observed all required forms to be posted. LPA observed functioning carbon monoxide and smoke alarms. There are adequate toys and equipment available for children. Outdoor play area was toured, and equipment appears to be in good condition and there is sufficient cushioning under the play structure, wood chips. Facility provides AM and PM snack and lunch to children in care. All food is prepared on site. Kitchen was toured at the time of inspection.

LPA reviewed children’s and staff files. At least one staff member present today has current Pediatric CPR and First Aid. LPA observed AB1207 Mandated Reporter training certificates for all staff. The Director was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

REPORT CONTINUED ON SUBSEQUENT PAGE, 809 C
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ST. PETER'S LUTHERAN SCHOOL
FACILITY NUMBER: 340320556
VISIT DATE: 09/07/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.


Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.


To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

A deficiency is being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A Type A violations regarding Staff Immunizations and a Type B Background Clearances have been assessed and documented on the subsequent 809-D page.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/07/2023 03:27 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: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
(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, the licensee did not comply with the section cited above in 5 out of 5 staff files which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2023
Plan of Correction
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Director shall acquire all staffs' proof of immunizations (TB, TDAP, MMR, Influenza or declination of Influenza) and keep the records in each staffs' file for department review. Facility will email proof of staff immunizations to the LPA by the POC due date.
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: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document is an Amendment of Original Document on 09/08/2023 10:47 AM

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: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

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 in because Staff 1 did not have current criminal record clearance association with this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Director shall submit a written statement indicating how she will ensure all staff is cleared and associated prior to working at the facility and make sure any future hires are checked through the Guardian website or through the licensing department. A Transfer of Criminal Record Clearance Request will be sent to LPA by the Plan of Correction Due Date 9/8/23.
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: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5