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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841130
Report Date: 05/01/2023
Date Signed: 05/01/2023 04:18:17 PM


Document Has Been Signed on 05/01/2023 04:18 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:MT. CALVARY LUTHERAN CENTERFACILITY NUMBER:
364841130
ADMINISTRATOR:RITA MANCINIFACILITY TYPE:
840
ADDRESS:27415 SCHOOL ROADTELEPHONE:
(909) 337-7750
CITY:LAKE ARROWHEADSTATE: CAZIP CODE:
92352
CAPACITY:12CENSUS: 8DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH: Facility Representative Kimberly KopeckyTIME COMPLETED:
04:30 PM
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On May 1, 2023 at 12:20 p.m., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced required one year inspection and met with facility representative Kimberly Kopecky. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. Eight (8) school age children, the Administrator and one (1) staff member were present at the facility during the inspection. The facility is located on the grounds of Mt. Calvary Lutheran Church. Center occupies a two story building, where the school age program is operated out of. This facility also operates a licensed preschool program (360908938). The school age program operates out of one (1) classroom (#3). The facility also has a staff office/reception area, staff bathrooms and an outdoor play space. The hours of operation are 8:00 a. m. to 5:00 p. m. Monday to Friday. The Center follows the Rim of the World School District calendar.
At approximately 1:05 p.m. LPA and the Administrator completed a safety inspection of the school age classroom.
Indoor/Children's Area: Child care center was observed to be clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean. Cleaning compounds were stored in a cabinet within the classroom. The cabinet was equipped with a latch. LPA observed the furniture/equipment is in good condition. Classrooms were free of flies, other insects, rodents. The classrooms had tables and chairs and various equipment to meet children’s needs. LPA observed each classroom had books, blocks, art supplies, and additional equipment that met the child's age and development. Children's belongings are kept in cubbies labeled with the children's names located at the entrance to the classroom. Trash cans for solid waste have tight fitting lids. Drinking water is readily available indoors via a drinking fountain and water bottles provided by the parents/authorized representatives. The water bottles are filled utilizing water from a lead tested faucet. All materials and surfaces are toxic free, window screens in good repair and free of debris. Report continued on page two
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MT. CALVARY LUTHERAN CENTER
FACILITY NUMBER: 364841130
VISIT DATE: 05/01/2023
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Report continued from page one
LPA observed a carbon monoxide detector, smoke detector and fire extinguisher located in the classroom. In addition, there are additional fire extinguishers located throughout the center. Fire extinguishers were serviced in 2023. There is one bathroom located in the school age classroom. The bathroom had one toilet and one sink which was functioning properly and age appropriate. LPA observed soap, toilet paper and paper towels readily available.
There was working telephone service within the facility. There is an isolation area for children who become ill. The facility maintains a comfortable temperature at all times. LPA reviewed the sign in/out sheets. Per review the sign in sheets were accurate and were completed daily. Smoking is prohibited on the premises. Teacher conducts daily inspection for illnesses. LPA did not observe prohibited childcare items during this inspection. Firearms/weapons are not allowed or stored on premises. LPA did not observe bodies of water on the premises.
Napping
The school age children do not nap at the Center however have a rest/quite time in the daily schedule.
Outdoor
LPA observed the outside play space. During this inspection, LPA observed the roof above the outdoor climbing structure, the slide, and the sand box sustained damage during the recent winter storm. LPA observed a four foot barrier surrounding the climbing structures making the damaged area inaccessible to the children in care. Per conversation with the facility representative the center is ensuring the children have access to bikes, balls and other large motor activities while the climbing structure is off limits. The outdoor play space is fully enclosed with a chain link fence. Dringk water is readily available when outdoors via the children's individual water bottles.
Health Related Services
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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. At the time of this inspection the facility was providing IMS services to zero school age children.
Report continued on page three
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MT. CALVARY LUTHERAN CENTER
FACILITY NUMBER: 364841130
VISIT DATE: 05/01/2023
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Report continued from page two

Facility Records
LPA observed a current roster and observed the disaster drill log. In addition, the facility had the required lead testing.

Posting Requirements
The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393), car seat law (PUB 269), emergency disaster plan, earthquake preparedness checklist.

Other: Electrical outlets are inaccessible, there are no recalled and or prohibited toys or sleep/play equipment observed on the premises.

During this inspection, LPA reviewed eight (8) child files. Per LPA's reviewed one (1) child file out of the eight (8) was missing documentation of the medical assessment. A technical advisory notice was issued. LPA reviewed three staff files. LPA advised the center to ensure all staff files have documentation of the required immunization's.

During the inspection, Facility representative was advised of the requirement to report Unusual Incidents. Facility representative informed to utilize the Unusual Incident Report/Injury Report LIC624 when submitting the report to the department (email address unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The On-Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.


Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Center shall permit the Department to inspect the child care center and to privately interview children or staff, to determine compliance with or to prevent violations of child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

Report continued on page four

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MT. CALVARY LUTHERAN CENTER
FACILITY NUMBER: 364841130
VISIT DATE: 05/01/2023
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Report continued from page three

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.

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/inspection-process.

Based on the inspection today, zero deficiencies are being cited. LPA provided two technical advisory notices.


A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Kimberly Kopecky.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6