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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911461
Report Date: 05/23/2023
Date Signed: 05/23/2023 05:48:30 PM

Document Has Been Signed on 05/23/2023 05:48 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:ZION LUTHERAN PRESCHOOLFACILITY NUMBER:
360911461
ADMINISTRATOR:M'LESS TRIPPLEFACILITY TYPE:
850
ADDRESS:15342 JERALDO DRIVETELEPHONE:
(760) 243-3074
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 124TOTAL ENROLLED CHILDREN: 124CENSUS: 13DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Lewis Busch, Administrator/PastorTIME COMPLETED:
06:00 PM
NARRATIVE
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On May 23, 2023, Licensing Program Analyst (LPA), Kuliema Calloway met with the facility Administrator/Pastor, and conducted a Required One Year inspection. LPA toured and inspected the preschool in accordance with the facility sketch. LPA observed 13 napping Pre-K (2- 4 yrs) children with two teachers’ aides (blue room) upon arrival. The facility consists of 4 classrooms (yellow, green, red, blue). The green room is currently not being used for classroom (only storage). There are also 2 additional classrooms located on the elementary school site used for 3rd to 6th grade two teachers were present and 24 children. The facility operates from 6:00am to 6:00pm. Monday through Friday. Incidental Medical Services (IMS) policy was discussed.
Indoor/Children's Area:, There are potential hazardous areas observed (ceiling needed repairs showing signs of leaking/damage in disrepair in (blue room) classroom used by pre-school children, floors are clean and safe, cleaning compounds are inaccessible, poisons locked, furniture and equipment in good condition, no insects or flies observed. There are age-appropriate books and learning material inside each classroom. Each classroom has labeled cubbies for the children, trash cans have tight fitting lids, no toxic materials observed, window screens in good repair. LPA observed the carbon monoxide and smoke detectors are operable. All Fire extinguishers were Full and meets standards. First Aid Kit is equipped with supplies and manual. The isolation area for ill children is in the office area, classroom temperature is comfortable, sign in/out sheets observed,
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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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: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461
VISIT DATE: 05/23/2023
NARRATIVE
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Per Pastor, no smoking on the premises. There is no prohibited play equipment on the premises.Telephone service was verified. Heating, lighting, and ventilation are in working condition. Per Pastor, drinking water is provided by children bringing their own water cups, once water is depleted, the cups are filled up with the tap water.

Napping: LPA observed cots in safe condition, sanitized after each use, cots spaced to have access to a safe walkway, bedding is not in contact with other bedding. The napping is clean, safe, sanitary and in good repair.


Restrooms: Age-appropriate toilets and sinks in working condition. Toilets and sink are safe, no hot water in restroom, paper towels observed for children use. There were no toilet seat covers in any of the children’s restrooms. LPA recommended seat covers for sanitation.
Health Related Services: Medications when used are inaccessible to children (locked in classroom), child name and date on medication, parent written consent as required.
Food Service: Food prepared and served in a safe manner, food preparation is completed in the kitchen (warming kitchen - no stove/oven), cleaning compounds are kept in the supply room (off limits), silverware are cleaned and sanitized after each use, refrigerator temperature in regulation, menu posted in kitchen, entry lobby, and classroom, breakfast and snack provided, if children bring own lunch, it is labeled.
Outdoor: Center has a shaded area, playground free from hazards and debris, play structure has cushioning material (sand), sandbox inspected regularly, air condition unit inaccessible. Preschool has separate, gated play area There was age-appropriate play equipment observed.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
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: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461
VISIT DATE: 05/23/2023
NARRATIVE
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Staff Records: LPA reviewed files for Director and Aide Qualifications, immunization, licensing forms (LIC9108, LIC 9150, Mandated Reporter, CPR/First Aid, LIC 503, LIC 308).
Children’s Records: Viewed for: (LIC 613, LIC 700, LIC 995, LIC 627, LIC 701).
Facility Records: LPA observed the Rosters. Fire/Earthquake drills are conducted monthly, LPA did not observe the drill logs.
Posting Requirements: Center has the following postings observed: (Facility License, PUB 393L, Emergency Disaster Plan, Menus, Personal Rights).
Documents Discussed: IMS (Incidental Medical Services), Earthquake/Fire Drill log, Sign in/out sheets, Earthquake Preparedness (LIC 9148), Daily Activity Schedule, LIC 624 Unusual Incident Report form.
Pastor 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. Care/supervision provided at all times, maintaining child/teacher ratios, and reporting requirements completing LIC 624B forms were discussed.

There were Type B deficiencies cited during the inspection. See 809 D pages.

Exit interview was conducted and this report was read aloud with the Pastor. A copy of this report and a Notice of Site Visit were given to Lewis Busch, at the facility.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/23/2023 05:48 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/23/2023 at 05:19 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: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101169(d)(18)
Application for License
(18) Evidence that the applicant has posted signs at the entrance to the child care center that provide the telephone number of the local health department and information on child passenger restraint systems pursuant to Health and Safety Code section 1596.95(g) and Vehicle Code sections 27360 and 27360.5.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above posting signs for age appropriate children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Center Administrator will provide proof to the Department no later than POC date of 5/30/23.
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Center Administrator will provide proof to the Department no later than POC date of 5/30/23.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2023 05:48 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/23/2023 at 05:19 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: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in maintaining the ceiling inside the classroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2023
Plan of Correction
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Center Administrator will repair ceiling and provide a copy of repair order to the Department no later than the POC date of 6/13/23.
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in providing proof that the center has had its water tested for lead in the water which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Center Administrator will schedule and provide proof of lead testing to the Department by POC date of 6/23/2023.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/23/2023 05:48 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/23/2023 at 05:19 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: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101230(c)(1)
Activities/Napping
(c) A teacher-child ratio of one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio specified in Section 101216.3(a) are immediately available at the center. (1) An aide who is 18 years of age or older, and who meets the requirements of Sections 101216 and 101216.2, may supervise 24 napping children in place of a teacher if the conditions specified in
(c) above are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of two teachers aides (S2 and S3) did not meet the aide education qualifications and were observed caring for napping children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Center Administrator will provide proof that the aides are qualified to assist children in teacher's absence to the Department no later than the POC date of 6/23/2023.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of three staff members did not have the Mandated Reporter training current in the staff files (S1, S2, and S3) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Center Adminstrator will provide proof to the Department that the training has been completed no later than POC date of 6/6/23.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/23/2023 05:48 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 05/23/2023 at 05:19 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: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review the licensee did not comply with the section cited above in one out of three staff members (S3) did not have TB and other immunizations in staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Center Administrator will provide proof to the Department that S3 has been immunized no later than POC date of 5/30/23
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in notifying the Department that S1 will be the new Director of the facility and previous Director has left the facility. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Center Administrator will provide necessary documentation to the Department of the current Director by the POC date of 6/6/23.
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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
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