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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614141
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:07:05 PM


Document Has Been Signed on 05/12/2022 12:07 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:FAITH LUTHERAN PRESCHOOLFACILITY NUMBER:
343614141
ADMINISTRATOR:MANGES, LISAFACILITY TYPE:
850
ADDRESS:4000 SAN JUAN AVETELEPHONE:
(916) 961-6069
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:45CENSUS: 28DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lisa MangesTIME COMPLETED:
12:30 PM
NARRATIVE
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All times on this report are approximations. At 9:30 a.m. on Thursday, May 12, 2022, Licensing Program Analyst (LPAs) Lea Habtom and Katrina Owens with Director, Lisa Manges, for the purpose of an unannounced 1 year required inspection. A COVID-19 risk assessment was conducted prior prior to entering the facility. Director guided LPAs on a tour of the facility, at which time a census of 28 preschool children supervised by 5 staff and director were observed in three classrooms, Frogs, Duck & Fish & Lizard. All individuals subject to criminal background review have obtained criminal record clearance. The hours of operations is 7:30 am- 5:30 pm Monday thru Friday.

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 and daily schedule. The menus were not posted for the snacks being provided. 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. The program has parents provide one snack and lunch. The facility provides one afternoon snack.

There are functional water fountains indoors and outdoors. Children also have labeled water bottles both indoor and outdoor. LPA observed both paper and electronic sign in and sign out sheet. Playground equipment and surfaces are free of loose or sharp parts. LPA observed sand cushioning beneath the play structure. Outdoor shade is provided by trees. There are no firearms or bodies of water on the premises. LPA observed a functional carbon monoxide detector.


At 10:00 a.m., 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 and mandated reporter certificates. http://www.mandatedreporterca.com/ (Report continues on 809-C)
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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Document Has Been Signed on 05/12/2022 12:07 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: FAITH LUTHERAN PRESCHOOL
FACILITY NUMBER: 343614141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101226(e)
Health-Related Services
(e) In centers where the licensee chooses to handle medications:

This requirement is not met as evidenced by:
Deficient Practice Statement
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(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.
Based on observation, the licensee did not comply with the section cited above in that their was an expired epipen, 2020, for a child who is currently enrolled which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Director corrected the deficiency by discarding the expired inhaler. Deficiency was cleared at the time of the visit.
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: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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Document Has Been Signed on 05/12/2022 12:07 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: FAITH LUTHERAN PRESCHOOL
FACILITY NUMBER: 343614141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(6)
Food Service
(6) Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the director did not comply with the section cited above in that there were no menus posted for the snacks provided which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2022
Plan of Correction
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The director agreed to email LPA L. Habtom a copy of the menu via email.
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: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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: FAITH LUTHERAN PRESCHOOL
FACILITY NUMBER: 343614141
VISIT DATE: 05/12/2022
NARRATIVE
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LPA reviewed children's records. Each child's file contained an emergency card, consent for emergency medical treatment, health history and notifications of children’s and parent’s rights.

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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s personnel, and administrative records. LPA made director aware of the expired epipen that was expired in 2020. LPA reminded the director to audit medication to confirm that all medication are current. 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.ht



LPA 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.

Director was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers.



Exit interview conducted and report was reviewed with the licensee Lisa Manges. 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: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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: FAITH LUTHERAN PRESCHOOL
FACILITY NUMBER: 343614141
VISIT DATE: 05/12/2022
NARRATIVE
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There were two deficiencies cited during today's visit. See page 809D for Type A & Type B deficiency.

This is a Type A deficiency, hence AB633 Notification Applies: Upon receipt of this report, the report must be posted along with the notice of site visit for 30 days for parents to view. Licensee must inform the parents/guardians of children in care at the facility and to the parents/guardians of children newly enrolled at the facility during the next 12 months via form LIC 9224 Acknowledgement of Receipt of Licensing Reports.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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