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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911461
Report Date: 02/08/2024
Date Signed: 02/08/2024 01:24:47 PM

Document Has Been Signed on 02/08/2024 01:24 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:ZION LUTHERAN PRESCHOOLFACILITY NUMBER:
360911461
ADMINISTRATOR:ROSEMARIE CARRIZOSAFACILITY TYPE:
850
ADDRESS:15342 JERALDO DRIVETELEPHONE:
(760) 243-3074
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 124TOTAL ENROLLED CHILDREN: 124CENSUS: 11DATE:
02/08/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Rosemarie Carrizosa, Director TIME COMPLETED:
02:00 PM
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On 02/08/2024, Licensing Program Analyst (LPA) Justeene Tamayo met with the facility Director Rosemarie Carrizosa, for the One Year Required inspection for the preschool age license in accordance with the facility sketch. A tour of the facility was conducted. Upon arrival LPA observed a total of 11 preschool children. There were 2 lead teachers supervising the preschool children, along with the Director. The hours of operation are 6AM-6PM Monday - Friday. Incidental Medical Services (IMS) were discussed.

Indoor/Children’s Area:
Child care center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean, cleaning compounds inaccessible, poisons locked, furniture/equipment is good condition, free of flies, other insects, rodents; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, each child has an individual permanent or portable storage space (cubby, individually labelled with name) for his/her clothing, personal belongings and or bedding (stored separately). There is a working telephone.

Trash cans for solid waste have tight fitting lids, drinking water is readily available indoors and outdoors (children's personal water bottles). All materials and surfaces are toxic free are inaccessible, no fireplace. The Fire Extinguisher (2A10BC) is in operable condition. Carbon monoxide and smoke detector is in working condition.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461
VISIT DATE: 02/08/2024
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Restrooms: LPA inspected and observed (5 toilets 6 sinks and 1 urinal). LPA observed soap, toilet paper and paper towels readily available. Water temperature is appropriate. There is an isolation area for children who become ill while in care located in the Directors office. Facility maintains a comfortable temperature at all times, first aid supplies (thermometer, bandages, scissors), sign in/out sheets (manually) available and completed daily. No Smoking prohibited on the premises, daily inspection for illness, no prohibited child care items observed. Firearms/weapons are not allowed or stored on premises. There is no body of water on the premises.

Napping: LPA observed cots in each of the classrooms.

Outdoor: The facility has one playground area for the preschool age children. Outdoor play equipment was inspected for health, safety, good repair and age appropriateness. There is concrete areas for active play. The area was observed to be free of debris, free from hazard, holes, broken items, debris, cushioning material underneath. No bodies of water were observed. There are areas for shade and rest. LPA observed outdoor play equipment to be in good repair.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461
VISIT DATE: 02/08/2024
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Teacher child ratios were observed and staff name recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.

Health Related Services: Medications inaccessible to children; all prescription and non-prescription medications have child’s name and are dated; written consent and instruction from child’s representative, a plan to document and report to child’s representative when medication is administered to a child; IMS plan on file (if applicable).

Children are inspected for illnesses (wellness policy) as they arrive. A review of medication policy indicated that prescription medication is administered only with parent's written permission (licensing medication form- LIC9221 - also used). LPA advised the Director must administer medication, and document the dosage, date and time onto a log. Medication can be brought and taken home by the parent daily. Medication will be properly labeled and stored in its original container.

This facility provides Incidental Medical Services – IMS. Currently no IMS.
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. 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/childquanda.htm

Food Service: Per Director, AM snacks and PM snacks are provided to the day care children. LPA observed kitchen area to be free of hazards. Per Director, current children enrolled do not have any food allergies.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461
VISIT DATE: 02/08/2024
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Staff/Personnel Records: Director (qualified) qualifications were verified, Designation of Responsibility observed, immunization's, TB clearance, health screening, criminal record statement, statement acknowledging suspected child abuse and mandated reporter were observed in file.

During review of staff files, Lead Teacher #2 did not have at least 12 units in Child Development, which poses a potential risk to children in care. Facility has been cited a Type B Citation. Please see LIC809-D for deficiency page.

Facility Records: Roster, fire/disaster drill log last completed on 01/01/2024. CPR/First Aid, and mandated report training were reviewed.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty.The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 394L), emergency disaster plan, earthquake preparedness checklist.

Documents Provided and or Discussed: Forms and records to keep at the facility and IMS.

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. CPR/First Aid expires on 08/19/2025. Mandated Reporter Training expires on 05/27/2025.

Electrical outlets are inaccessible, recalled and or prohibited toys/play equipment were not observed on the premises. There are no window cords accessible to children.

Sign in and out sheets were reviewed. The parent board was reviewed and has all of the required forms posted. Fire/earthquake drills current. Roster current.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: ZION LUTHERAN PRESCHOOL
FACILITY NUMBER: 360911461
VISIT DATE: 02/08/2024
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Director advised of the requirement to report Unusual Incidents. Lead Teacher informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.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 family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

Director 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.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Director shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of child care center 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.

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/process


A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
No deficiency. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.

Exit interview conducted and report was reviewed with Director Rosemarie Carrizosa. This report was read and provided to the Director Rosemarie Carrizosa, along with her appeal rights and Notice of Site Visit.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2024 01:24 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 02/08/2024 at 12:53 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.1(c)(1)
Teacher Qualifications and Duties
(c) To be a fully qualified teacher, a teacher shall have one of the following: (1) Twelve postsecondary semester or equivalent quarter units in early childhood education or child development completed, with passing grades, at an accredited or approved college or university; and at least six months of work experience in a licensed child care center or comparable group child care program.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Lead Teacher #2 did not have all 12 units in early childhood development, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Director shall send an exception letter to LPA Tamayo no later than 03/15/24 and ensure staff #2 has all required child development class units before staff #2 is a lead teacher.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mariela Ramon
LICENSING EVALUATOR NAME:Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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