372005706-11-28-2023-51-CC-ALMA-CY22SP-20231128163926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372005706
Report Date: 11/28/2023
Date Signed: 11/28/2023 04:39:35 PM

Document Has Been Signed on 11/28/2023 04:39 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: 4	DATE:	11/28/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Laura Shilling		TIME COMPLETED:	05:00 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 11/28/23 at 1:30 PM, Licensing Program Analyst (LPA) Adrian Mangina visited the facility to conduct an annual inspection. Upon arrival LPA met with Facility Representative Laura Shilling and proceeded to tour the facility. During today's inspection, there were 4 children with 1 teacher in one classroom. The second classroom is currently not in use and is being utilized by the aftercare program temporarily until enrollment increases. Appropriate ratios, capacity and supervision were observed. Furniture and age-appropriate equipment is in good condition. Rooms have adequate heating, lighting, ventilation. Floors appear to be clean and safe. Drinking water is readily accessible. Bathrooms are maintained with operational toilets and faucets with appropriate temperature. Paper towels and toilet paper are available. Bathroom is lighted and has ventilation. Facility serves snacks only. Food service is conducted in classroom and consists of snacks only. Menu is posted. Adequate food is available for snacks. 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. Children bring their own lunch. 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. Storage areas for poisons are locked. Director stated there are no firearms or other weapons on the premises. There is an operational carbon monoxide detector at the facility. Last fire drill was conducted on 10/17/23 and last earthquake drill was conducted on 9/18/23. There are no bodies of water observed at the facility. Outdoor play area is a fenced playground with sufficient material for cushioning. All equipment is age appropriate. Facility Representative states there are no bodies of water or weapons at this facility. Climbing structures, swings and slides are securely fixed to the ground. Area has trees, shade sails, and large canopies used for shade. Area has safe filtered drinking water readily accessible as children bring their own water bottles which are refilled with filtered water. Grounds are free of debris or potential hazards. continued on LIC809 page 2

SUPERVISOR'S NAME: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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 5

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: 11/28/2023

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
26
27
28
29
30
31
32

LIC 809 page 2

LPA reviewed medication storage which is a locked cabinet in the classroom. There are currently no children taking medications. LPA reviewed staff files. All staff have required immunizations. LPA observed 2 of 3 staff (staff 2 and staff 3) have expired mandated reporter training certificates. Staff 1 has no TDAP. Each personnel record contains documentation of educational background and training. LPA reviewed five child files. Sleep logs are present. Children’s records contain admission agreements and medical assessment. Licensee reminded to ensure each file has signed LIC995A. Sign ins were reviewed. Facility utilizes Brightwheel for sign ins.

LPA discussed the safe sleep regulations representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

Facility representative 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.

Facility representative 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.

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.

continued on LIC809 page 3

SUPERVISOR'S NAME: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: 11/28/2023

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
26
27
28
29
30
31
32

LIC809 page 3

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.

• CCC COMPLETED TESTING 11/14/22 AND THERE ARE NO LEAD EXCEEDANCES.

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/.

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.

See LIC 809-D for Type B deficiencies cited

Exit interview conducted and report was reviewed with the Facility Representative, Laura Shilling. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 11/28/2023 04:39 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: 11/28/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as staff 2 and staff 3 have expired manadated reporter training certificates which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	Facility Representative states will provide LPA with completed mandated reporter training certificates and complete files for staff 1, staff 2 and staff 3 no later than close of business 12/11/23.

Section Cited

Personnel Requirements


	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: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 11/28/2023 04:39 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: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101223(b)(1)

Personal Rights

(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]). 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 child 2, child 3, and child 4 have incomplete child files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	Facility representative states will provide complete child files for child 2, child 3, and child 4 no later than close of busines 12/11/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/28/2023
	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: Renesha Askew	TELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L Mangina	TELEPHONE: (619) 629-6197
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5