Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191200465
Report Date: 06/16/2017
Date Signed: 06/16/2017 02:57:45 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2017 and conducted by Evaluator Silva Garibyan
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20170613120355
FACILITY NAME:SHERMAN OAKS LUTHERAN CHILDREN'S CENTERFACILITY NUMBER:
191200465
ADMINISTRATOR:DIANE NIXONFACILITY TYPE:
850
ADDRESS:14847 DICKENS STREETTELEPHONE:
(818) 784-9480
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:78CENSUS: 0DATE:
06/16/2017
UNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Diane NixonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Record Keeping: Child was not signed out on Sign in/out sheet

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Silva Garibyan and Myriam Luga , conducted a complaint visit regarding the above mentioned allegation. LPAs met with and interviewed the facility Director Based on the information obtained from interviews conducted and documentation reviewed, the above allegation substantiated.

LPA reviewed sign-in and out sheets for the week of 06/05/17 and 06/12/2017. LPAs observed that the child was not signed out on 06/09/2017.

Based on the information obtained from the interviews conducted and observations by the LPAs, the above allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview conducted and a copy of this report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2


Control Number 30-CC-20170613120355

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6167 BRISTOL PARKWAY #400
CULVER CITY, CA 90230
FACILITY NAME: SHERMAN OAKS LUTHERAN CHILDREN'S CENTER
FACILITY NUMBER: 191200465
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2017
Section Cited
101229.1(b)
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Sign in and Sign out:
The licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following:
(1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

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The director shall enforce this requirement by reminding staff and parents/guardians to sign in/out the children daily with a full legal signature.
Full signature will be required on the sign out sheet. Director will immediately train staff on Sign in and Sign out regulation, and retain proof that include staff's signatures for attending and understanding procedures for record.
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LPAs reviewed sign in/out sheets. On 6/09/17 a child was not signed out.
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Director will to create a memo that will be given to the parents informing them of the requirement and importance of properly signing their children in and out daily. Director will submit a proof of correction to the Department by 06/30/2017
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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: Mary RuizTELEPHONE: (310) 337-4826
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (310) 337-3754
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2017
LIC9099 (FAS) - (06/04)
Page: 2 of 2