372005706-12-13-2022-51-CC-ALMA-CM3SA7-20221213124152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372005706
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:42:08 PM

Document Has Been Signed on 12/13/2022 12:42 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	REFORMATION LUTHERAN CHURCH/SCHOOL		FACILITY NUMBER:	372005706
ADMINISTRATOR:	BRENNAN BUTH		FACILITY TYPE:	850
ADDRESS:	4670 MOUNT ABERNATHY AVENUE		TELEPHONE:	(858) 279-1117
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	52	CENSUS: 16	DATE:	12/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Brennan Buth		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/13/22 at 9:00 AM, Licensing Program Analyst (LPA) Adrian Mangina visited the facility to conduct an annual inspection. Upon arrival LPA met with Director Brennan Buth and proceeded to tour the facility. During today's inspection, there were 16 children with 2 staff in 1 classroom. The second licensed classroom (room 8) is not currently enrolled due to staffing issues. Appropriate ratios and capacity were observed. Appropriate care & visual supervision were also observed during the inspection while children were seated during an activity. Furniture and age appropriate equipment is in good condition. Room has adequate heating, lighting, ventilation. Floors appear to be clean and safe. Drinking water is readily accessible. Facility uses drinking water from a dedicated filtering system. Bathrooms are maintained with operational toilets and faucets with appropriate temperature. There is one toilet and sink in the classroom and another two bathrooms: girls room has 5 toilets and one sink and boys room has three toilets and three urinals and two sinks for use by both classrooms. Director will request a waiver for shared use of the large bathrooms as class 3A/3B has 21 total children enrolled. Paper towels and toilet paper are available. Bathroom is lighted and has ventilation. There is no food service area. Children bring their own lunch and the facility provides snacks which are prepared in the classrooms. Adequate food is available for snacks. Snack menu is posted monthly. Cleaning supplies are kept separate from food and are inaccessible to children. Storage containers for solid waste have tight-fitting covers and are kept in good repair. Director states there are no poisons on premises. Director stated there are no firearms or other weapons on the premises. All foods/beverages capable of rapid spoiling are stored in covered containers at 45 F or less. The facility appears to be free of insects and rodents. There is an operational carbon monoxide detector and smoke alarm at the facility. Last fire drill was conducted on 3/25/22 and last earthquake drill was conducted on 3/25/22. Director was reminded that disaster drills must be conducted every 6 months. The fire department last inspected the facility on 4/2/19. (continued on LIC809-C...)

SUPERVISOR'S NAME: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: REFORMATION LUTHERAN CHURCH/SCHOOL	FACILITY NUMBER: 372005706
	VISIT DATE: 12/13/2022

NARRATIVE

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LIC809 page 2

Outdoor play area is a fenced playground with sufficient material for cushioning. There are no bodies of water or weapons at this facility. Climbing structures, swings and slides are securely fixed to the ground. Area has tree, covered play equipment and a shaded sand box for shade. Equipment is age appropriate. Area has drinking water (fountain) readily accessible and grounds are free of debris or potential hazards.

At least one staff member has current CPR and First Aid certifications. Two of three staff have required immunizations. Staff #3 is missing MMR, Health Screening, and TB. Each personnel record contains documentation of educational background and training. Sign ins were reviewed. Children’s records contain admission agreements and medical assessment. A review of staff records on this date indicates that all staff members are associated to the facility. All facility staff who require caregiver background checks have received criminal record and child abuse clearances or exemptions. 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.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

continued on LIC809 page

SUPERVISOR'S NAME: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: REFORMATION LUTHERAN CHURCH/SCHOOL	FACILITY NUMBER: 372005706
	VISIT DATE: 12/13/2022

NARRATIVE

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LIC809 page 3

This facility provides Incidental Medical Services – IMS. Facility hasan Incidental Medical Services Plan. Director states that there are no children currently taking medications . Director states will keep medications in her locked office. Director has locked boxes for both refrigerated and non-refrigerated medications. 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

Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiencies were cited (refer to LIC 809-D).

Exit interview conducted and report was reviewed with the facility representative, Brennan Buth A notice of site visit was given and must remain posted for 30 days.

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.

SUPERVISOR'S NAME: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 12/13/2022 12:42 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: REFORMATION LUTHERAN CHURCH/SCHOOL	FACILITY NUMBER: 372005706
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101174(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. 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 as last disaster drills were conducted on 3/25/22 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2023
	Plan of Correction
1 2 3 4	Facility Representative states will conduct earthquake and fire drill and provide proof to LPA no later than close of busieness 1/10/22,

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one of three staff (staff #3) does not have MMR, TB, or Health Screening on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2023
	Plan of Correction
1 2 3 4	Facility Representative states will ensure that staff #3 has complete file and provide proof to LPA no later than close of busieness 1/10/22, and that in future will ensure that all staff files are complete.

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: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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