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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360904126
Report Date: 09/12/2025
Date Signed: 09/12/2025 03:44:41 PM

Document Has Been Signed on 09/12/2025 03:44 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:FAITH LUTHERAN DAY CARE CENTERFACILITY NUMBER:
360904126
ADMINISTRATOR/
DIRECTOR:		JOY KIRBYFACILITY TYPE:
850
ADDRESS:12449 CALIFORNIA STREETTELEPHONE:
(909) 790-1816
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 30TOTAL ENROLLED CHILDREN: 16CENSUS: 12DATE:
09/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Laura Salazar, Interim DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 09/12/2025 at 1:25 PM, Licensing Program Analyst (LPA) Raymond Moorehead conducted a case management inspection with Interim Director Laura Salazar. A case management inspection is being conducted in response to the receipt of an Unusual Incident Report (UIR) from the facility. The UIR was received by the licensing agency on 09/08/2025 as the incident was self-reported. The incident took place on 08/28/2025.

The UIR documented an incident where a child was reportedly left behind for approximately 30-45 seconds, as their classroom was transitioning into their main classroom. Further, it was stated that the entire incident was observed by a parent that was in the parking lot during drop off time in the morning. There were no injuries that were reported to occur as a result of the reported incident.

During today's visit, LPA investigated the reported incident. Facility staff members were interviewed, documentation was obtained, a tour/census was taken, and LPA inspected the area where the incident took place. During interviews, the following was disclosed. It was stated that the the subject teacher had a total of 6 children present. Further, it was stated that the subject teacher double counted a child and the last child was not observed attempting to go inside the classroom, whom was outside the class at the time.

Pertinent interviews also stated that the subject child was able to open the door and re-enter the classroom within that time frame of 30-45 seconds after the subject teacher closed the door. It was also stated that the subject child was not in fear, but thought it was a "silly" accident that had occurred.
NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Raymond Moorehead
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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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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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: FAITH LUTHERAN DAY CARE CENTER
FACILITY NUMBER: 360904126
VISIT DATE: 09/12/2025
NARRATIVE
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Based on the information obtained during today's visit, it was determined that Title 22 Regulation section 101229(a)(1) (Responsibility for providing Care and Supervision) was violated. The Regulation states that no child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

See LIC809-D for cited deficiency.

The following plans of corrections have already been implemented and discussed during today's visit:

1.) Each teacher had individual trainings with Interim Director, in regards to supervision
2.) Each teacher received a counseling form from the facility, which is considered a formal warning
3.) The facility has implemented the use Child Supervision Records (CSR)
4.) The facility has implemented the use of the Name-To-Face feature on the Procare application.
5.) The facility will have an all-staff training on 10/31/2025 for supervision.

During today's visit, LPA obtained proof that the following plan of correct has already been implemented at the facility. LPA conducted an exit interview with Laura Salazar, Interim Director and provided a copy of this report.

Interim Director was informed that this report dated 09/12/2025 documents 1 Type A Citation. Type A citations shall be posted for 30 consecutive days as there was an immediate risks to the health, safety, or personal rights of children in care.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Also, Interim Director was informed to provide a copy of this licensing report dated 09/12/2025 that documents any Type A citation 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.

NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Raymond Moorehead
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2025 03:44 PM - It Cannot Be Edited


Created By: Raymond Moorehead On 09/12/2025 at 03:08 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: FAITH LUTHERAN DAY CARE CENTER
FACILITY NUMBER: 360904126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2025
Section Cited
CCR
101229(a)(1)

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Based on the information obtained during today's visit, it was determined that Title 22 Regulation section 101229(A)(1) (Responsibility for providing Care and Supervision) was violated. The Regulation states that no child(ren) shall be left without the supervision of a.....
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The following plans of corrections have been implemented and discussed during today's visit:
1.) Individual trainings for all teachers
2.) Counseling forms for all teachers
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teacher at any time...Supervision shall include visual observation. It was determined that a preschool child's class transitioned into their classroom and one child was left behind for approximately 30-45 seconds. However, the child was observed by a parent in the parking lot.
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3.) Implementation of Child Supervision Records (CSR)
4.) Implementation of the use of the Name-To-Face feature on the Procare application.
5.) The facility will have an all-staff training on 10/31/2025 for supervision.

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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.
Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:
Raymond Moorehead
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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