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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911138
Report Date: 02/14/2025
Date Signed: 02/14/2025 02:06:13 PM

Document Has Been Signed on 02/14/2025 02:06 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:IMMANUEL LUTHERAN PRESCHOOLFACILITY NUMBER:
330911138
ADMINISTRATOR/
DIRECTOR:		TRONA SALGADOFACILITY TYPE:
850
ADDRESS:5455 ALESSANDRO BLVD.TELEPHONE:
(951) 682-4211
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 87TOTAL ENROLLED CHILDREN: 87CENSUS: 33DATE:
02/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Angie Knapp and Jean Kempe- Co DirectorsTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On the date and time listed above, a case management visit was completed by Licensing Program Analysts (LPAs) Giselle Carbullido and Chase Atherton due to deficiencies found during the course of another inspection.
1) Criminal Record clearance- 101170(e)(1)) Record review and interviews revealed staff have been working at the facility without clearance and association to the facility.
2) Reporting Requirements: Facility did not report to Community Care Licensing within 10 days of a change of child care center director or designee(s) per Title 22 Division 12 regulation 101212(b)
SEE LIC 809-D for the deficiencies cited.
The Co- Directors, Angie Knapp and Jean Kempe were provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.
LPAs Carbullido and Atherton informed facility representatives Angie Knapp and Jean Kempe that this report dated 02/14/25 document(s) one type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPAs Carbullido and Atherton informed the facility representatives Angie Knapp and Jean Kempe to provide a copy of this licensing report dated 02/14/25 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
An exit interview was conducted, a copy of this report and Notice of Site Visit was provided to the Co-Directors and the LPAs observed the Notice of Site Visit form was posted by staff. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC UPON REQUEST FOR THREE YEARS.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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 02/14/2025 02:06 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 02/14/2025 at 01:39 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: IMMANUEL LUTHERAN PRESCHOOL
FACILITY NUMBER: 330911138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2025
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance: 1) Obtain a California clearance or a criminal record exemption as required by the Department or. This requirement is not met as evidenced by:
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Facility will submit proof of finger print clearance and association for S1 to the department by POC due date 02/18/25. (Due date extended due to weekend and state holiday)
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Based on records reviewed and interviews conducted the facility did not ensure all staff are fingerprint cleared and associated to the facility. This is an immediate 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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 02:06 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 02/14/2025 at 01:48 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: IMMANUEL LUTHERAN PRESCHOOL
FACILITY NUMBER: 330911138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2025
Section Cited
CCR
101212(b)

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101212(b) Reporting Requirements
(b) The name of the child care center director, ... shall be reported to the Department within 10 days of a change of child care center director ... This requirement was not met as evidenced by:
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Facility will submit notification to the department from Licensee on director assignments for the facility by POC due date 02/18/25.
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Based on records reviewed and interviews conducted the facility did not report to the department a change in directors from December 2024. This is a potential 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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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