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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376600052
Report Date: 10/07/2021
Date Signed: 10/07/2021 12:00:11 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2021 and conducted by Evaluator James Wilkerson
PUBLIC
COMPLAINT CONTROL NUMBER: 10-CC-20210928115451
FACILITY NAME:CHRIST THE KING LUTHERAN PRESCHOOLFACILITY NUMBER:
376600052
ADMINISTRATOR:COSTA, ANGELAFACILITY TYPE:
850
ADDRESS:1620 SOUTH STAGECOACHTELEPHONE:
(760) 728-7908
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:68CENSUS: 32DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Angela CostaTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Unqualified staff working at day care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) James Wilkerson arrived at this facility to conduct an investigation into the above allegation. LPA toured the facility and conducted census. It was alleged that an unqualified staff member is caring for the children by him/herself while a qualified teacher goes on break. LPA observed S1 caring for seven children on the playground without a qualified staff being present. S1 stated to LPA that he/she is a Teacher's Aide and the the teacher is on a break. Based on LPA's observation that S1 was alone with the seven children and S1's admission the he/she is not a qualified teacher and is alone with these seven children the above allegation is SUBSTANTIATED.

SEE LIC 9099D for deficiency cited.

A Notice of Site Visit was posted and a copy of this report was provided to Ms. Costa on this date.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 10-CC-20210928115451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHRIST THE KING LUTHERAN PRESCHOOL
FACILITY NUMBER: 376600052
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited
CCR
101216.2(e)
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Teacher Aide Qualifications and Duties - An aide shall work only under the direct supervision of a teacher. This requirement was not met as LPA observed a Teacher's Aide working alone with seven children on the playground without a qualified teacher being present. This is a potential risk to the health and

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Director, Angela Costa agrees to submit in writing to Community Care LIcensing on how to prevent this from occurring in the future.
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of safety of children in care.
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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: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: James WilkersonTELEPHONE: (951) 218-7031
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2