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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200465
Report Date: 03/22/2024
Date Signed: 04/09/2024 02:31:08 PM

Document Has Been Signed on 04/09/2024 02:31 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
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: 78TOTAL ENROLLED CHILDREN: 57CENSUS: 43DATE:
03/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Kimberly OgasTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/22/2024, Licensing Program Analyst's (LPA) Suzette Ornelas conducted an unannounced case management inspection for the purpose of deficiencies observed during a complaint investigation for complaint control #58-CC-20240313091018. Upon arrival LPA was greeted by Director, Kimberly Ogas and observed 43 children and 10 adults.

LPA Ornelas investigated complaint control # 58-CC-20240313091018. According to the complaint investigation report received on 3/13/2024. An unusual incident occurred 1/16/2024.

Based on interview conducted with Director, It was confirmed that there was an attempt made to report the unusual incident to the case carrying LPA on 1/16/2024; however, no direct contact with the on duty worker was made and an Unusual Incident Report (LIC624) was not submitted to the department within 7 days at ESROsupportstaff@dss.ca.gov

LPA explained to the Director that when an incident occurs, according to Title 22 Regulations, the incident must be reported to the department within 24 hrs., and a written report using the unusual incident /injury report LIC624 form must be filled out and mailed to the department within 7 days. Director understands and will comply.

LPA Ornelas provided Director with a copy of the Reporting Requirements regulation, LIC624 and the phone number to contact the on duty analyst (424-301-3077).

The following Type B deficiency is being cited on 3/22/2024 in accordance to Title 22 of the California Code of Regulations: 101212(d)Reporting Requirements. Please refer to LIC809-D for cited deficiency.

A copy of this report, notice of site visit, and appeal rights were provided. The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with the Director
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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 04/09/2024 02:31 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 03/22/2024 at 02:56 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SHERMAN OAKS LUTHERAN CHILDREN'S CENTER
FACILITY NUMBER: 191200465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
101212(d)(1)(D)

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101212(d)(1)(D)Reporting Requirements
(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (D) Any suspected physical or psychological abuse of any child.
This requirement is not met as evidence by:
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Director agrees to watch the Reporting Requirements Video at:

ccld.childcarevideos.org

and provide a summary to LPA via email at
suzette.ornelas@dss.ca.gov
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Based on interviews and observations, Director did not comply with reporting requirements, which poses a potential risk to the health and safety of children in care.
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Director agrees to complete and submit the LIC624.

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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:Betty Bell
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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