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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700265
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:02:52 PM

Document Has Been Signed on 03/27/2024 02:02 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
430700265
ADMINISTRATOR:MCDERMOTT, PENNYFACILITY TYPE:
850
ADDRESS:3149 WAVERLY STREETTELEPHONE:
(650) 493-8942
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 20DATE:
03/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Felicity AckersTIME COMPLETED:
02:10 PM
NARRATIVE
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On March 27, 2024 at 9:30am, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced and conducted a Case Management Inspection while at the facility for another reason. LPA met with head teacher Felicity Ackers as director Regina Imlach is currently on leave. Present today were 20 children and an additional 3 staff members.

During a tour of the facility, LPA observed medication for child C1 was stored in a zip lock pouch, and not in it's original container with an unaltered label.

See LIC809D for deficiencies cited during today's inspection. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

Exit interview conducted with facility representative Felicity Ackers. A notice of site visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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Document Has Been Signed on 03/27/2024 02:02 PM - It Cannot Be Edited


Created By: Julia Placencia On 03/27/2024 at 01:13 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 430700265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
101226(e)(1)(B)

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101226(e)(1)(B) Health-Related Services-
(e) In centers where the licensee chooses to handle medications:(1)All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (B)Each container shall have an unaltered label.
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Director shall ensure C1's medication is stored inaccessible in the facility and in it's original container and with an unaltered label.
***Additionally, director is to submit a statement ensuring compliance of this regulation and include photos. Submit proof to LPA by due date of 4/9/24.
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This required is not met as evidenced by:
Based on observation, C1's medications are kept in a zip lock pouch and not in its original container with an unaltered label. This is a potential health and safety risk to child(ren) in care.
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***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Jason Jang
LICENSING EVALUATOR NAME:Julia Placencia
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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