360908938-4-24-2023-12-CC-KZIS-CR7VKE-20230424163014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360908938
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:30:45 PM

Document Has Been Signed on 04/24/2023 04:30 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	MT. CALVARY LUTHERAN PRESCHOOL		FACILITY NUMBER:	360908938
ADMINISTRATOR:	RITA MANCINI		FACILITY TYPE:	850
ADDRESS:	27415 SCHOOL ROAD		TELEPHONE:	(909) 337-7750
CITY:	CREST PARK	STATE: CA	ZIP CODE:	92326
CAPACITY: 84	TOTAL ENROLLED CHILDREN: 50	CENSUS: 20	DATE:	04/24/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Facility Representative, Kimberly Kopecky		TIME COMPLETED:	04:30 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 April 24, 2023 at 11:25 a.m., Licensing Program Analyst (LPA) Kendal Zirbes conducted an unannounced Case Management Annual Continuation inspection and met with Administrator Kimberly Kopecky. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. 20 preschool children, the Administrator and five (5) staff members were present at the facility during the inspection. At approximately 11:35 LPA and the Administrator completed a safety inspection of the preschool. No deficiencies were observed with the physical plant. During this inspection, LPA reviewed 11 child files. Per LPA's reviewed one (1) child file out of the 11 did not have updated immunization records. LPA advised the Center to ensure the child's files have updated immunization's after enrollment. A technical advisory notice was issued. LPA reviewed six staff files. Four of the six staff files were incomplete and missing required documentation. Of the four incomplete files two files were missing the Health Screening, and three files were missing documentation of the staff members immunizations. A type B citation was issued, refer to LIC 809D During the inspection, Facility representative was advised of the requirement to report Unusual Incidents. Facility representative informed to utilize the Unusual Incident Report/Injury Report LIC624 when submitting the report to the department (email address unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of center. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The On-Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm. Report continued on page two

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 04/24/2023 04:30 PM - It Cannot Be Edited

Created By: Kendal Zirbes On 04/24/2023 at 03:32 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL	FACILITY NUMBER: 360908938
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four of six personnel records did not contain all required information. Two of six staff files were missing the Health Screening, three of six staff files were missing documentation of the staff members immunization's. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2023
	Plan of Correction
1 2 3 4	Per Administrator, the facility will utilize the LIC 311 and will make a new checklist to use for review of the staff files. A copy of the new checklist and the missing paperwork will be submitted to the Department.

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.

SUPERVISOR'S NAME:

Lady King

LICENSING EVALUATOR NAME:

Kendal Zirbes

LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL	FACILITY NUMBER: 360908938
	VISIT DATE: 04/24/2023

NARRATIVE

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Report continued from page one

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Center shall permit the Department to inspect the child care center and to privately interview children or staff, to determine compliance with or to prevent violations of child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Based on the inspection today, one deficiency is being cited based on LPAs record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Kimberly Kopecky.

SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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