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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360905326
Report Date: 12/02/2021
Date Signed: 12/03/2021 09:15:20 AM

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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CHRIST LUTHERAN PRESCHOOL AND KINDERGARTENFACILITY NUMBER:
360905326
ADMINISTRATOR:STACEY STRASSERFACILITY TYPE:
850
ADDRESS:5500 FRANCIS AVENUETELEPHONE:
(909) 627-1433
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:90CENSUS: 18DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Director Stacey StrasserTIME COMPLETED:
05:10 PM
NARRATIVE
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On 12/02/2021, Licensing Program Analysts (LPAs) Destinee Hogue and Blanca Ruiz-Silva conducted a required annual inspection as part of a compliance review. A tour of the inside and outside of the facility was granted and the following was observed and discussed with Director, Stacey Strasser:

A review of staff records and children's records were conducted as part of this evaluation.

· The following items have been posted and are updated where necessary:
v License
v Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
v Parent’s Rights Poster (PUB393)
v Personal Rights (LIC613A),
v Child Car Seat Law
v Menu

· There are no bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· No weapons stored at the facility
· Hazards are stored where inaccessible to children which include: disinfectants, cleaning solutions and other items that are dangerous to children.
· Poisons and toxins were inaccessible, however poisons and toxins were not locked, at the time of this inspection. SEE LIC809D for cited deficiencies.
· Medications are stored where inaccessible to children
· Classrooms are equipped with age appropriate furniture and equipment in good condition.
· Furniture and equipment shall be in good condition, free of sharp, loose, or pointed parts.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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 18
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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
VISIT DATE: 12/02/2021
NARRATIVE
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· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· The surface of the outdoor activity space is free of hazards. LPA observed rubber mulch surrounding the outdoor activity space.
· All toilets, handwashing, and bathing facilities are in safe and operating condition, at this time.
· All floors were observed to be clean and free from hazards
· Food preparation area is clean and free of vermin
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins have tight-fitting covers that were on and in good repair, at this time.
· Uncontaminated drinking water shall be readily available both indoors and out. Drinking water is supplied by water faucet with water jug and plastic cups in each classroom and some children bring their own cups.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall.
· The Licensee shall ensure the facility is free of flies, other insects and rodents.
· Outdoor activity space surfaces shall be free of hazards.
· Appropriate smoke detector and fire extinguisher is present. Facility did not have a carbon monoxide present at the time of this inspection.
· Director understands the Child Care Center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
· The Department has inspection authority as specified in Health & Safety Code sections 1596.852, 1596.853, and 1596.8535.
· The Department shall notify a Licensee to immediately terminate the employment of, or to remove/bar any person with specified convictions or for other reasons. The Licensee shall comply with the notice.
· The facility is operating within the terms of the license.
· A review of staff records on 12/02/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
· A Staff member is present with current Pediatric CPR/First Aid which expires on 02/2022 and closing staff CPR/First Aid expires on 02/2022.
· Sign in/Sign out record was reviewed and does not meet regulation requirements, at this time.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
VISIT DATE: 12/02/2021
NARRATIVE
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· Each Staff’s files does not contain the required health screening as specified in section 101216(g). Director understands all personnel, including the Licensee, Administrator and Volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks.
· Personnel that pose a threat to the health and safety of children shall be relieved of their duties.
· All personnel shall be given on-the-job training…or shall have related experience that demonstrates knowledge of and skill in…housekeeping and sanitation principles, including universal health precautions.
· Appropriate supervision was provided during this inspection. Director understands the facility shall ensure no child(ren) shall be left without the supervision, including visual supervision, of a teacher at any time.
· Ratios were met during this inspection. Director understands there shall be a ratio of one Teacher supervising no more than 12 children in attendance.
· Director shall ensure that each child is accorded a safe, healthful and comfortable accommodations, furnishings and equipment to meet the child's needs.
· The Director is responsible for ensuring that children with obvious symptoms of illness including, but not limited to, fever or vomiting, are not accepted.
· The facility is equipped to isolate and care for any child who becomes ill during the day. The front office is used as an isolation area.
· Each child’s file contains the required identification and emergency information, however children files did not have a completed medical assessment on file.
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized
· Review of staff records does not contain proof staff are immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year or provide a statement denying the influenza vaccination.
· Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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) / (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.htm.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
VISIT DATE: 12/02/2021
NARRATIVE
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- Director 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.

- To improve the quality and value of the new inspection process, a survey will be sent to the email address provided.y 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/inspection-process.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov



· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· The Duty Officer is available to answer questions Monday – Friday from 8:00am to 5:00pm at (951)782-4200

· Access to forms & Regulations for a Child Care Center are online at www.cdss.ca.gov.

See LIC809D for cited deficiencies.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. THE DIRECTOR UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC809 & LIC809D) CITED DURING THIS INSPECTION. A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (WITHIN 24 HOURS OF THE CHILD’S NEXT DAY IN CARE) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS (AT THE TIME OF ENROLLMENT).

If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH. Exit interview conducted and report was reviewed with the Director, Stacey Strasser

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and tour, the licensee did not comply with the section cited above in, During observation and tour, Director admitted the facility does not have a working carbon monoxide dectector present at the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2021
Plan of Correction
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Immediately (within 24 hours), Director agrees to install a carbon monoxide detector, at the facility and agrees to submit proof of installed carbon monoxide detector. Proof of installed carbon monoxide detector can be submitted by video via email or text message.
Type A
Section Cited
CCR
101227(a)(1)
Food Service
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children. Each meal shall include, at a minimum, the amount of food components as specified by Title 7, Code of Federal Regulations, Part 226.20, (Revised January 1, 1990) Requirements for Meals, for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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, during LPAs observation and inspection of the kitchen area, LPAs observed expired "Signature Select Saltine Crackers" stored in the kitchen cabinets. Crackers were labeled to be used by August 23, 2021 and per facility Snack Menu and Director admission, crackers were served to children in the month of December 2021 and November 2021. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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During this inspection, Director removed the crackers from the kitchen cabinet and disposed the expired crackers in the kitchen trash can.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 11 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)(1)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. (1) Storage areas for poisons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in, during LPAs observation and inspection of the Yellow and Green Classroom, LPAs observed a spray bottle labeled "bleach," and Comet Classic Antibacterial Spray Cleaner present in the Yellow and Green classrooms. Both bottles were inaccessible to children in care, however the bottles were not stored behind a key-lock cabinet. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2021
Plan of Correction
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During this inspection, Director removed the bottles from the Yellow and Green classroom and placed the items behind a locked storage room located in the kitchen. Director agrees to install a key-lock for poisons and toxins in each classroom. Proof of installed key-lock can be submitted via email or mail by POC due date.
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, the licensee did not comply with the section cited above in, Staff#1 is missing MMR series, Staff#2 is missing Tdap. Staff#1 and #2 are missing proof of influenza and/or statement declining the influenza vaccine. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2022
Plan of Correction
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Director agrees to submit proof of MMR series for Staff #1 and proof of Tdap for Staff #2. Proof can be submitted via email or mail by POC due date.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 10 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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, Staff#1 and Staff#3 have an expired mandated reporter certificate and Staff#2 and Staff#4 do not have a certificate available for review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2021
Plan of Correction
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Director agrees to submit proof of AB1207 Mandated Child Abuse Reporter certificate for Staff #1-Staff #4 by POC due date. Director agrees to submit proof of AB1207 via email or mail.
Type B
Section Cited
CCR
101216.1(c)(1)
Teacher Qualifications and Duties
(c) To be a fully qualified teacher, a teacher shall have one of the following: (1) Twelve postsecondary semester or equivalent quarter units in early childhood education or child development completed, with passing grades, at an accredited or approved college or university; and at least six months of work experience in a licensed child care center or comparable group child care program.

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, Staff#2 did not have required Child Development Units available for review. Staff #2 is missing Child Growth & Dev and Child Family & Community. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2022
Plan of Correction
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Director agrees to submit proof of completed Child Growth & Development and Child Family & Community for Staff #2 and/or proof of enrollment in Child Growth & Development and Child Family & Community by POC due date via email or mail.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 5 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Child #3, Child #6 and Child #8 did not have LIC701-Physician Report present at the time of this inspection. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2022
Plan of Correction
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Director agrees to submit LIC701-Physician Report for Child #3, Child #6, and Child #8 via email or mail by POC due date.
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in Child #2, Child #3, Child #8, and Child #10 did not have immunization records present at the time of this inspection. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2022
Plan of Correction
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Director agrees to submit proof of immunizations (CDPH286) for Child #2, Child #3, Child #8, and Child #10 via email or mail by POC due date.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 16 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Child #1-Child #10 did not have Admission Agreement present at the time of this inspection. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2022
Plan of Correction
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2
3
4
Director agrees to submit Admission Agreement for Child #1-Child #10 via email or mail by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 7 of 18
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL AND KINDERGARTEN
FACILITY NUMBER: 360905326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance. (e) All individuals subject to a criminal record review...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)

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on record review, the licensee did not comply with the section cited above in, upon arrival to the facility LPAs observed Staff#1 present at the facility providing care and supervision for 5 daycare chiildren in the Purple Classroom. During records review, it was confirmed with Director that Staff#1 has a criminal record clerance, however a criminal record transfer request was not submitted for Staff #1 until 12/02/2021. Based on facility records, Staff #1 was officially hired on 11/15/2021. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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During this inspection, Director combined Purple and Yellow classroom and provided the LIC9182, LIC508 and copy of CA Driver's License to CCL. During this inspection, LPAs provided CCL association_disassociation862@dss.ca.gov email address to Director.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
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