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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603677
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:02:31 PM

Document Has Been Signed on 06/09/2022 02:02 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:HOLY TRINITY LUTHERAN CHILD CARE CENTERFACILITY NUMBER:
191603677
ADMINISTRATOR:KORY HIGGINSFACILITY TYPE:
850
ADDRESS:9300 CRENSHAW BLVDTELEPHONE:
(323) 757-4850
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 85TOTAL ENROLLED CHILDREN: 85CENSUS: DATE:
06/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Zenaida Ontiveros, Assistant DirectorTIME COMPLETED:
02:10 PM
NARRATIVE
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On 06/09/2022 Licensing Program Analyst (LPA) Shandra Powell conducted a Case Management - Deficiencies inspection due to an observation made during a walk-through of the facility. LPA observed Staff#1 with Staff#2 in classroom with children providing care to children.

During the course of the inspection and file review it was determine Staff #1 did not have a criminal background check clearance nor a criminal record clearance transfer request on file. This poses an immediate risk to the health and safety of children in care.

Also, during the course of the inspection and file review it was determine Staff #1 did not have the required Immunization's, Measles, Pertussis, & Influenza, on file. This poses a potential risk to the health and safety of the children in care

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return for the next 12 months. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months. Asst. Director was provided with a blank copy of the Parent Acknowledgement of Receipt of Licensing Reports Form (LIC9224).
The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

An exit interview was conducted and a copy of this report, appeal rights and notice of site visit was given to Ms. Ontiveros, Assistant Director.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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 06/09/2022 02:02 PM - It Cannot Be Edited


Created By: Shandra Powell On 06/09/2022 at 01:14 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOLY TRINITY LUTHERAN CHILD CARE CENTER
FACILITY NUMBER: 191603677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited
CCR
101170(e)(2)

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
Request a transfer of a criminal record clearance.
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LPA gave Guardian Portal information to Board Members and Administration Assistant during inspection. Staff#1 will be associated to facility by POC date of 06/10/2022.
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This requirement was not met as evidenced by criminal record clearance association list. Staff#1 is not associated to the facility and has been working at the facility since May 31st 2022. This is an immidiate risk to the health and 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:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


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Document Has Been Signed on 06/09/2022 02:02 PM - It Cannot Be Edited


Created By: Shandra Powell On 06/09/2022 at 01:19 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: HOLY TRINITY LUTHERAN CHILD CARE CENTER
FACILITY NUMBER: 191603677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
HSC
1596.7995(c)

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Employees or volunteers at day care center; immunization requirements; records; exemptions. The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in
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Staff will provide facility with Immunization records by POC date of 06/10/2022.
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the person’s personnel record that is maintained by the day care center.During this inspection Proof of Immunization (Pertussis, Measles, and Influenza) was missing from staff #1 file.
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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:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
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