300606156-3-9-2026-06-CC-AFCN-DRZTRZ-20260309145821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300606156
Report Date: 03/09/2026
Date Signed: 03/09/2026 02:58:35 PM

Document Has Been Signed on 03/09/2026 02:58 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	TRINITY LUTHERAN CHURCH & CHRISTIAN SCHOOL		FACILITY NUMBER:	300606156
ADMINISTRATOR/ DIRECTOR:	HEMPHILL, ASHLEY		FACILITY TYPE:	850
ADDRESS:	4101 EAST NOHL RANCH ROAD		TELEPHONE:	(714) 637-8370
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 82	CENSUS: 39	DATE:	03/09/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Director Ashley Hemphill		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 03/09/2026 at 11:30am, Licensing Program Analyst (LPA), Anna Chan conducted an unannounced onsite inspection for the purpose of an Annual Random Visit. LPA met with Director Ashley Hemphill. LPA and Director toured the facility inside and outside and the floor and yard plan were verified. Census was taken in individual classrooms. The overall census observed was 39 preschool children and 7 staff. Children were having lunch outdoors when LPA arrived. Director stated there are 82 children enrolled in the program. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7a.m.- 6p.m., Monday through Friday. The facility has 3 types of programs: Half Day 8am-11:45am, Mid-Day 8:00am-3:15pm, and Full Day 7am-6pm. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms were clean and sanitary. Food is brought from home. There is drinking water available to children indoors by water filling station and sports bottle are also brought by children from home with the child’s name on it. Page 1 of 3

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 03/09/2026 02:58 PM - It Cannot Be Edited

Created By: Anna Francesca Chan On 03/09/2026 at 01:28 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: TRINITY LUTHERAN CHURCH & CHRISTIAN SCHOOL	FACILITY NUMBER: 300606156
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(2)

Health-Related Services

(2) All prescription and nonprescription medications shall be maintained with the child's name and shall be dated. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above, 5 medications were expired. 1 medication had a replacement and the expired medication was not discarded nor return to child's authorized representative which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/09/2026
	Plan of Correction
1 2 3 4	Director stated they have a checklist of medication. Director stated they will provide LPA of a PLan of Action to make sure medications are up to date.

Section Cited


	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.

	Martha Malane
NAME OF LICENSING PROGRAM MANAGER:

	Anna Francesca Chan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: TRINITY LUTHERAN CHURCH & CHRISTIAN SCHOOL	FACILITY NUMBER: 300606156
	VISIT DATE: 03/09/2026

NARRATIVE

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Children nap on cots, and bedding were stored individually. Blankets and sheets are brought home weekly for washing. The facility has a working carbon monoxide detector and fire extinguisher. The facility has conducted an emergency drill on October 16, 2025. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The cushioning material is turf grass around the climbing equipment which appeared to be enough to absorbs falls. There is also a part of the playground that has paved area for bikes. Drinking water in the outdoor activity space is provided by water filling stations and sports bottles with the child’s name on it. The facility grounds were safe, sanitary, in good repair and free of hazards. There are no bodies of water present at the facility, and none was observed during today’s visit.

5 Children's records were reviewed, and there was a separate, complete and current record for each child. Sign in/out procedure reviewed through Bright wheel. Each child representative has their own code to sign in and out a child.

6 Staff files were reviewed for staff present during the facility inspection on this date. Health screening and immunization as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 8/2026.

Currently there are medications in the facility. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.
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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: TRINITY LUTHERAN CHURCH & CHRISTIAN SCHOOL	FACILITY NUMBER: 300606156
	VISIT DATE: 03/09/2026

NARRATIVE

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The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA observed 5 medications were expired. 1 of 5 medications (epinephrine) were replaced with a new one. Medication was not discarded nor given back to child representatives. "All prescription and nonprescription medications shall be maintained with the child's name and shall be dated." LPA reminded the director to ensure medications are being checked as needed or have a checklist of medication for monitoring.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES:
Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, require 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. 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 on April 9, 2025. Director stated they use Sparkletts water to refill children's water bottle.

Transfer Request (LIC9182). The Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov and may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

In the areas that were evaluated, the following type B violation was observed and being cited in accordance with Health and Safety Code 101226(e)(2) Health-Related Services at the time of the visit. See LIC809D.

An Inspection and exit interview were completed with Director Ashley Hemphill. The report and deficiency were reviewed and discussed. Notice of Site visit was posted and must be posted for 30 consecutive days. Appeal Rights were provided.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026

LIC809 (FAS) - (06/04)

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