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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197414470
Report Date: 09/16/2025
Date Signed: 09/16/2025 05:58:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2025 and conducted by Evaluator Tatiana Bickham
PUBLIC
COMPLAINT CONTROL NUMBER: 58-CC-20250801110317
FACILITY NAME:SHEPHERD OF THE VALLEY LUTHERAN CHURCHFACILITY NUMBER:
197414470
ADMINISTRATOR:SUZANNE LEGUMFACILITY TYPE:
850
ADDRESS:23838 KITTRIDGE STREETTELEPHONE:
(818) 347-6784
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:104CENSUS: 10DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
04:33 PM
MET WITH:Season EngTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Unqualified staff are providing care to children.
Facility is operating out of ratio.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced site visit on 09/16/2025 at 3:40 PM to this facility to deliver findings on the above-mentioned allegations. Upon arrival, LPA met with Adminstrator Wendy Torres and Director Season Eng, and explained the purpose of the visit. There were 10 children (1 toddler) being supervised by 2 staff at the time of visit.

During the course of the investigation, interviews were conducted with Director. LPA reviewed sign in and out sheets for children, staff files, and staff time cards. Copies of the children's and staff rosters were also obtained and reviewed.

Per Reporting Party, unqualified staff are providing care to children and facility is operating out of ratio.

Per interview with the Director, the facility was operating a summer camp program. The Director stated
Page 1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 58-CC-20250801110317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SHEPHERD OF THE VALLEY LUTHERAN CHURCH
FACILITY NUMBER: 197414470
VISIT DATE: 09/16/2025
NARRATIVE
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that the summer camp followed the same structure as the school-year program, with an increased emphasis on activities. According to the Director, the enrolled children ranged in age from 18 months to 5 years.

The Director reported that there were occasions when toddlers were dropped off in the morning with another staff member that did not have infant/toddler units. All children were dropped off in one classroom. The Director, who is a fully qualified infant/toddler teacher, stated she was always present on campus when the facility opened, although she was not clocked in at that time. Per Director staff-to-child ratios were consistently maintained, and the summer camp concluded on August 1, 2025.

LPA reviewed sign-in and sign-out sheets for children enrolled during the summer program. LPA observed that toddler were being dropped off early in the morning. Upon reviewing staff timesheets and personnel files, LPA did not find documentation indicating that qualified staff with infant/toddler units were clocked in during those early hours. LPA asked the Director if any documentation could be provided to confirm her presence with staff during opening hours, the Director stated she was present but did not provide any supporting documentation.

During the file review, LPA observed that toddlers were in care with unqualified staff, which placed the facility out of ratio.

Based on LPA’s observations and file reviews, the allegation of Licensee is allowing unqualified staff to provide care to day care children is Substantiated. Meaning the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), are being cited on the attached LIC 9099D.

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.  A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year).  The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent.  Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. 

Exit interview was conducted with Director Season Eng. Appeals Rights and the Notice of Site visit were provided. The Notice of Site Visit must remain posted for 30 days during the hours of operation. Failure to maintain posting as required will result in a civil penalty of $100.00.
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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 58-CC-20250801110317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SHEPHERD OF THE VALLEY LUTHERAN CHURCH
FACILITY NUMBER: 197414470
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2025
Section Cited
HSC
1596.955(4)
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4) The maximum group size, with two teachers, or one fully qualified teacher and one aide, does not exceed 12 toddlers.
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Director will write a statement stating the facility understands toddler children must be supervised by a qualified toddler teacher.
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This requirement was not met as evidenced by LPA observations of children's sign in and out sheets, staff records and time sheets which showed there was no qualified toddler teacher supervising toddlers making the facility out of ratio.
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Type B
09/30/2025
Section Cited
CCR
101416.2(b)
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Prior to employment, an infant care teacher shall have completed, with passing grades, at least three postsecondary semesters or equivalent quarter units in early childhood education or child development, and three postsecondary semester or equivalent quarter units related to the care of infants, at an accredited or approved college or university.
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Director stated they will submit a waiver request to have preschool and toddler children together during morning care and after care hours.
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This requirement was not met as evidenced by LPA observations of time sheets, staff files and staff timecards. LPA did not observe a qualified staff with infant/toddler units at the time toddlers arrived at the center. This poses a potential health and safety risk to 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.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3