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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364840047
Report Date: 04/11/2022
Date Signed: 04/11/2022 03:18:43 PM


Document Has Been Signed on 04/11/2022 03:18 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:CALVARY CHAPEL LAKE ARROWHEAD ROCK PRESCHOOLFACILITY NUMBER:
364840047
ADMINISTRATOR:SANDY GREENEFACILITY TYPE:
850
ADDRESS:101 GRANDVIEW ROADTELEPHONE:
(909) 337-2468
CITY:TWIN PEAKSSTATE: CAZIP CODE:
92391
CAPACITY:38CENSUS: 27DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Director, Elisa EllisTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Zirbes met with the Director/Administrator Elisa Ellis for the purpose of conducting an unannounced Required one year inspection. LPA toured and inspected the entire center, which consists of three classrooms, four children's restrooms, and two outdoor play spaces. The Center is located on the grounds of Calvary Chapel Lake Arrowhead Church. LPA observed three classrooms in use with a total of 27 preschool children. The following staff were present: Director/Administrator and three teachers. The facility operates from 7:00am until 5:30pm Monday through Friday.
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 were inaccessible, poisons locked, furniture/equipment is good condition. The Center was free of flies, other insects, or rodents. All classrooms were equipped with tables and chairs 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 their clothing, personal belongings and or bedding. Trash cans for solid waste have tight fitting lids, drinking water is readily available indoors and outdoors. All materials and surfaces are toxic free. No fireplaces were present. There is a working carbon monoxide detector, smoke detector and fire extinguishers (2A10BC) located in each classroom and throughout the Center. The Center had working telephone service on the premises. There is an isolation room for children who become ill while in care located in the Directors office. The facility maintains a comfortable temperature at all times. LPA observed first aid supplies located in each classroom. LPA advised the Director to inspect each first aid kit to ensure all required contents are enclosed. Electronic sign in/out sheets were available and are completed each day.

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SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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: CALVARY CHAPEL LAKE ARROWHEAD ROCK PRESCHOOL
FACILITY NUMBER: 364840047
VISIT DATE: 04/11/2022
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When the children are playing outside they bring their individual water bottles. Smoking prohibited on the premises. Staff complete daily inspections for illness. LPA did not observe prohibited child care items at this time. Firearms/weapons are not allowed or stored on premises. There are no bodies of water on the premises. The Center does not provide meals or snacks. All meals are provided by the parents and stored in the child's labeled lunch boxes.

Napping
Cots used are utilized and were observed to be in good condition at the time of his inspection. Bedding and linens were individually stored so that each child's bedding is identifiable, and no child's used bedding comes into contact with other bedding.

Restrooms
There are four children's restrooms located on the grounds. Each of the three classrooms has a restroom with at least one toilet and one sink. When the children are outside they utilize the churches restroom located near the outdoor play space. Changing tables were observed in Classroom 1 (Bees) and Classroom 3 (Butterflies). At the time of this inspection all restroom areas were in safe and in sanitary operating condition. The children's restrooms deliver hot and cold water. LPA observed paper towel (touchless) and soap dispensers were available for the children. Additional restrooms available for the staff in the preschool office.
Outdoor
The Center has two outdoor play areas. One of the outdoor play areas consisted of large and small climbing equipment, monkey bars, a canoe, tricycles, balls and additional materials which met the ages of the children enrolled. The large climbing structure had two slides and a climbing area. The small and large climbing equipment was placed on a wood chips, which is a cushioned material that can absorb falls. The climbing equipment was securely anchored to the ground. At the time of this inspection, the slide on the large climbing structure was not in use due to safety concern. The Center took appropriate steps and made the area inaccessible via the use of caution tape being placed at the entrance and exit of the slide. All other equipment was free from hazards, holes, broken items. A fence surrounds the outdoor area. The second play area had a dramatic play kitchen space, a sand box, and additional materials which met the ages of the children enrolled. No bodies of water were observed in the license spaces of the Center.
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SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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: CALVARY CHAPEL LAKE ARROWHEAD ROCK PRESCHOOL
FACILITY NUMBER: 364840047
VISIT DATE: 04/11/2022
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Health Related Services
A review of medication policy indicated that only prescription medication is administered and only with parent's written permission. At the time of this inspection, no medications are being administered or stored on the premises. If medications are required, they are stored within combination locked containers placed on a inaccessible shelf in each classroom. Refrigerated medications are stored in mini refrigerators located in each classroom. .

This facility provides Incidental Medical Services – 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/childqanda.htm

Staff/Personnel Records
LPA reviewed 10 child records and four staff files during this inspection. Records were complete and contained the required documentation.

Facility Records


LPA and Facility representative reviewed the LIC 311A Records To Be Maintained At The Facility. LPA observed a current roster, disaster drill log, current CPR/First Aid with expiration date of 01/15/2024 and current mandated reporter training which expires 3/18/2024.

Posting Requirements
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 393L), car seat law (PUB 269), emergency disaster plan.

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SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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: CALVARY CHAPEL LAKE ARROWHEAD ROCK PRESCHOOL
FACILITY NUMBER: 364840047
VISIT DATE: 04/11/2022
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Other: Electrical outlets are inaccessible, there are no recalled and or prohibited toys or sleep/play equipment observed on the premises.

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



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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.


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SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: CALVARY CHAPEL LAKE ARROWHEAD ROCK PRESCHOOL
FACILITY NUMBER: 364840047
VISIT DATE: 04/11/2022
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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

No deficiencies were observed during this inspection. An Advisory notice was provided to the Director regarding the first aid kits.

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 Elisa Ellis.

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC809 (FAS) - (06/04)
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