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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191223870
Report Date: 04/04/2023
Date Signed: 04/04/2023 02:17:38 PM

Document Has Been Signed on 04/04/2023 02:17 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:GRACE LUTHERAN SCHOOLFACILITY NUMBER:
191223870
ADMINISTRATOR:TERRI TURNERFACILITY TYPE:
850
ADDRESS:856 WEST NEWGROVE STREETTELEPHONE:
(661) 948-1018
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 22DATE:
04/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Administrative Assistant Christine CalvertTIME COMPLETED:
02:30 PM
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On 4/4/2023 at 11:02, Licensing Program Analyst (LPA) Andrea Pittman met with Administrative Assistant Christine Calvert to conduct a case management visit. She was permitted access to the facility. LPA toured the facility according to the facility sketch.

On 3/30/2023 at 2:36, the LPA received the Unusual Incident Report (UIR) for the bottom lip injury sustained to Child 1 while under the care and supervision of Staff 1 and Staff 2 while playing outside in the preschool play area.

During the visit on 4/4/2023, the LPA conducted a record review, spoke with relevant parties, and observed the area the incident occurred and it is determined that there is no violation to Title 22 Regulation in regards to the injury sustained by Child 1.
During the record review at 12:52pm, LPA observed the sign-in sheets on 3/30/2023 were signed by Staff 2 and the Staff 2 admitted that the parent/guardian/authorized representative often rush off before signing the sign-in sheet and she signs in for the parents/guardians/authorized representatives when they do not sign in and places an identifier of who dropped-off/picked-up the child and she initials. This is a Type B Violation.

The Licensee plans to correct this violation by completing a staff training, a newsletter to remind all parents/guardians/authorized representatives of the requirement to sign-in and sign-out and the Licensee will have the parents/guardians/authorized representatives sign a written statement acknowledging the requirement to sign-in and sign-out when dropping off and picking up the children in care due by 4/18/2023.

Per Title 22 Regulations, this facility is not in compliance and a Type B Deficiency has been cited. Please, see the LIC 809D for the citation.

An exit interview was conducted with Administrative Assistant Christine Calvert and a copy of this Report, a Notice of Site Visit, and Appeal Rights were provided on this day.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrea Pittman
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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Document Has Been Signed on 04/04/2023 02:17 PM - It Cannot Be Edited


Created By: Andrea Pittman On 04/04/2023 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GRACE LUTHERAN SCHOOL
FACILITY NUMBER: 191223870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2023
Section Cited
CCR
101229.1(b)

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101229.1(b) Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement was not met as evidenced by:
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Admin. Asst agrees to complete a staff training, to provide the newsletter reminding parents of the requirement of signing the sign-in sheet at drop-off and pick-up and to have all enrolled student's parents sign a written form acknowledging the requirement. The Admin Asst. can send via e-mail/fax the newsletter, training agenda, and sign-in sheets no later than Tuesday, 4/18/2023.
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Based on the observation, interview, and
record review of the LPA, the Licensee did not meet the requirement as Staff 2 signed in and out for 13 records of signing in and/or out on the 3/30/2023 sign-in sheet which poses a potential Health, Safety, or
Personal Rights risk to persons 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:Mariela Ramon
LICENSING EVALUATOR NAME:Andrea Pittman
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
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