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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421700134
Report Date: 12/06/2023
Date Signed: 12/06/2023 05:14:58 PM

Document Has Been Signed on 12/06/2023 05:14 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
421700134
ADMINISTRATOR:KATHY LYNN LEDOUXFACILITY TYPE:
850
ADDRESS:420 EAST FESLERTELEPHONE:
(805) 922-5419
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 63TOTAL ENROLLED CHILDREN: 63CENSUS: 18DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Kathy Lynn LedouxTIME COMPLETED:
05:30 PM
NARRATIVE
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On 12/6/2023, Licensing Program Analysts (LPAs) Francisca Velazquez and Elvin Baddley conducted an unannounced Case Management inspection for the purpose completing a case management incident inspection at the Child Care Center (CCC). LPAs met with Kathy Lynn Ledoux, administrator of the Child Care Center. Administrator was advised of the purpose of this inspection. LPAs observe eighteen (18) children being supervised by two (2) staff. The CCC staff informed LPAs that Director was out in a personal appointment. Director arrived at the facility around 4:30 PM.

Based on the information provided by staff at the CCC during this inspection, it was revealed S1 noticed C1 was missing from the outdoor playyard. During this time, S1 was in the bathroom and when S1 walked out of the bathroom S1 noticed C1 was not in the outdoor yard. S1 then proceed to walk out of the CCC towards Broadway Street looking for C1 and then returned towards School St. When S1 was on School Street, S1 observed C1 with three (3) adults (two females and one male). S1 and adults walked toward each other where the adults handed C1 over to S1. S1 reported C1 was out of the CCC for about 10 minutes.

The CCC notify CCLD of the incident that occurred on 12/6/2023, of a child wandering from the CCC.

Today, deficiency cited under Title 22 Division 12 Appeal rights given. Civil penalty assessed during today's inspection. Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report.

Exit interview conducted and report was reviewed with the licensee, Crystal Corkern.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 12/06/2023 05:14 PM - It Cannot Be Edited


Created By: Francisca Velazquez On 12/06/2023 at 04:47 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 421700134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
101229(a)(1)

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 (a)The licensee shall provide care and supervision as necessary to meet the children's needs. (1)No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement was not met as evidenced:
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Director agrees to submit plan of correction detailing how the CCC will ensure the supervision of children is met at all times. Director will submit plan of correction by 12/7/23 via email Francisca.Velazquez@dss.ca.gov
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Based on interviews with CCC staff it was revealed C1 wandered out of the CCC for about 10 mintues without any CCC staff noticing C1 was missing. This is an immediate risk to the health, safety and personal rights to the children in care.
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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:Maria Mueller
LICENSING EVALUATOR NAME:Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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