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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593330
Report Date: 04/27/2026
Date Signed: 04/27/2026 04:47:35 PM

Document Has Been Signed on 04/27/2026 04:47 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CAREFACILITY NUMBER:
191593330
ADMINISTRATOR/
DIRECTOR:		PATRICIA MARTINEZFACILITY TYPE:
850
ADDRESS:2110 W. FRANCISQUITO AVE.TELEPHONE:
(626) 962-1899
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 55TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
04/27/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Yesenia Garcia, VolunteerTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analysts (LPA) Cynthia Reyes conducted an unannounced annual site Inspection to ensure the health and safety standards as required by the regulations governing childcare centers are met for this Preschool program. LPA met with Yesenia Garcia, Volunteer who is fingerprint cleared and Sarahy Romero who is not fingerprint cleared with 5 day care children napping. Director Patricia Martinez was called and arrived 40 minutes later. The days and hours of operation are Monday to Friday from 6 AM to 6 PM. This program is located on the Mt. Calvery church site. A copy of the Entrance Checklist for Child Care Centers form (LIC 125) was provided to Patricia when she arrived.

LPA began the tour of the facility with Patricia who stating, parents will enter the facility from the parking lot of the church, Parents sign in/out is done right outside classroom #4. Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. The parent board is located outside classroom #4 where the sign in/out sheet is. Not all the licensing required postings are posted and visible for all to see. Facility has telephone service as well as an email and both were verified. The director was advised that the email may be public information. Director stated there are no weapons, firearms or swimming pools/bodies of water on the premises. The Children’s roster (LIC 9040) with 08 children enrolled & Staff Personnel report (LIC 500) with total 6 staff was reviewed for completeness.

The ill/isolation area is located in class room #2 and the children will use the staff rest room located outside that class room. A mat will be used for the ill child to use and rest if needed. Other children will be combined in another class room. Health checks are conducted in the class room when they arrive.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Cynthia Reyes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330
VISIT DATE: 04/27/2026
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LPA was guided through the preschool classrooms #1-5. During the tour LPA took staff names, position and children's census.
  • Room #5 consist of 0 teacher, 0 aide with 0 total children. (Room not in use at this time)
  • Room #4 consist of 0 teacher, 1 aide with 5 total children. Director present in room. (+2 volunteers)
  • Room #3 consist of 0 teacher, 0 aide with 0 total children. (Room not in use at this time)
  • Room #2 consist of 0 teacher, 0 aide with 0 total children. (Room not in use at this time)
  • Room #1 consist of 0 teacher, 0 aide with 0 total children. (Room not in use at this time)


Teacher child ratios were discussed in accordance with Title 22 Regulations and observed. LPA observed the licensed facility is not within the conditions, limitations, and capacity specified on the license. LPA discussed Responsibility for Providing Care and Supervision that children should be under direct supervision and observation, including visual supervision, of a teacher at all times. (LPA observed two (2) Volunteers present alone with five (5) children napping.

The following in the classrooms were also observed by LPA during this inspection. Toys and play equipment were observed to be age appropriate clean and safe. All surfaces and materials accessible to children, including toys, are toxic free, age-appropriate fixtures, furniture, equipment and supplies and all was inspected for age appropriateness and is in good repair. LPA observed and inspected napping equipment (cots) & are age appropriate and in good repair. Sheets/blankets are provided by the parents and taken home and washed every Friday. Appropriate Individual storage space was observed to be available for each child and cleanliness was observed in the room. LPA observed the facility has central heat and air, overhead lights as well as natural light. The facility will provide water by jugs and cups and the children can bring their own labeled water bottles/Sippy cups.

LPA observed all restrooms used by children are in good condition, water temperature, paper towels, toilet paper, and all were inspected for safety, sanitation and operable. Childcare centers shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Cynthia Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330
VISIT DATE: 04/27/2026
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Licensing staff was then guided to the outdoor play area. The outdoor play yard is self-contained by a gate around it. Water will be used by jugs, cups and children’s own water bottles while outdoors. LPA observed age-appropriate outdoor toys, play equipment and materials to be clean, safe and in good repair, as well as adequate shade available by use of large trees and the building. All areas around play equipment and slides are cushioned with material to absorb a fall. LPA advised the licensee that the children need to be within the direct care and supervision, including visual observation and supervision of the teacher(s) at all times. All areas identified on the Facility Sketch were inspected.

Children food: Facility provides breakfast, parents provide lunch, and PM snack. Menus were observed to be posted and reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative. The facility has a food pre area and is in the class room for snacks only. LPA observed a refrigerator and microwave and a large storage cabinet if needed space was inspected for safety and cleanliness. Licensee will take measures to keep the facility free of flies, other insects and rodents. All food and drinks are to be labeled with the expiration date visible for all to see. Containers used to discard food have tight fitting lids. The facility has extra linen and food available if needed.

Carbon monoxide detectors and smoke detectors are present and are in operable condition in each classroom. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. The fire extinguisher type 2A-10BC (Service date: 02/09/2026) must be serviced annually or as often as necessary. Fire and earthquake drills must be done every 3 months and documented (Last drill 04/08/2026). Hazardous items including disinfectants, poisonous, cleaning solutions and any other items that could pose a danger to children were observed to be stored inaccessible to children.



Facility has No transportation policy. Licensee states that any lifesaving medication will be stored in a locked area inaccessible to children in care. First aid supplies were observed to have all the required items including a thermometer. There is a fully equipped first aid kit available in each classroom.

AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Cynthia Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 4 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330
VISIT DATE: 04/27/2026
NARRATIVE
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Children’s Records were reviewed for completeness. Inspection of required forms were made and documented on the LIC 857.

Staff records, which are documented on the LIC 859. Staff present will be verified to have proof against TB, measles, pertussis, and influenza, as well as current Mandated reporter. LPA observed during staff file review, that there is at least one person present on this date and at all times, with Pediatric CPR & First Aid. Children's roster & Staff Personnel report was reviewed for completeness.

Criminal Records clearance: Licensee was reminded that all adults 18 and over including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Lead Testing: Assembly Bill (AB) 2370, Chapter 676, statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water used for drinking and food preparation) for lead contamination before January 1, 2023 and then every 5 years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21,1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21,1-CCP. LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and water Testing Information.

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 PIN 22-02- CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/resources/child-care-centers/
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Cynthia Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 5 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330
VISIT DATE: 04/27/2026
NARRATIVE
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Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation (within 24 hours by telephone call) and documented on the form LIC624B and submitted within 7 days by email, fax or mailed to the department. UIR Email: MPROincidentreports@dss.ca.gov


MyChildCarePlan.org – Licensee, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms.

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 Care tools, please send email inquiries 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.



To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

The department has On Duty Workers available for questions Monday through Friday at (323) 981-3350 from 8:00 AM - 5:00 PM. To access forms and regulations go online at: www.ccld.ca.gov.

Based on Licensing staff observations, interviews, and record review, there are Deficiencies being cited on this date. The following deficiency listed on the attached LIC 809-D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiency that are being cited needs to be cleared to protect the children’s health & safety.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Cynthia Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 6 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330
VISIT DATE: 04/27/2026
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LPA provided consultation during this inspection, as well as a copy of the 311A was also given.

Exit interview conducted and report was reviewed with Patricia Martinez, Director.

A notice of site visit was given and must remain posted for 30 days.

LPA, Cynthia Reyes informed Patricia Martinez, Director, that this report dated 04/27/2026 document(s) (1) Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety or personal rights of a child in care.

Also, LPA, Reyes informed Director, to provide a copy of this licensing report dated 04/27/2026 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months (1 year) from the date of this report.

A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or written statement, must be placed in the child’s file for verification. The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Child Development Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Cynthia Reyes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 04/27/2026 04:47 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 04/27/2026 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101229(a)(1)
Responsibility for Providing Care and Supervision
(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, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

2 unqualified volunteers were alone caring for day care children
POC Due Date: 04/27/2026
Plan of Correction
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Director states the volunteers will not be used at the day care until they meet all the licensing requirements. Director states will write the department a declaration with the detailed steps she will take to ensure volunteers are not used until they meet the requirements.
Type A
Section Cited
CCR
101230(c)
Activities/Napping
(c) A teacher-child ratio of one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio specified in Section 101216.3(a) are immediately available at the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

2 unqualified volunteers were alone caring for day care children during nap time.
POC Due Date: 04/27/2026
Plan of Correction
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Director states the volunteers will not be used at the day care until they meet all the licensing requirements. Director states will write the department a declaration with the detailed steps she will take to ensure volunteers are not used until they meet the requirements.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Reyes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 04/27/2026 04:47 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 04/27/2026 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

A volunteer was present with children and no fingerprint clearance and no qualified staff present.
POC Due Date: 04/27/2026
Plan of Correction
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Director states the volunteers will not be used at the day care until they meet all the licensing requirements. Director states will write the department a declaration with the detailed steps she will take to ensure volunteers are not used until they meet the requirements.
Type A
Section Cited
CCR
101170(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of volunteers that require fingerprinting.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

The facility does not have any proof of volunteer #4 fingerprint documentation on file.
POC Due Date: 04/27/2026
Plan of Correction
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Director states the volunteers will not be used at the day care until they meet all the licensing requirements. Director states will write the department a declaration with the detailed steps she will take to ensure volunteers are not used until they meet the requirements.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Reyes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 04/27/2026 04:47 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 04/27/2026 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101216.1(a)
Teacher Qualifications and Duties
(a) In addition to Section 101216, the following shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

2 volunteers with no units were observed alone with day care children
POC Due Date: 04/27/2026
Plan of Correction
1
2
3
4
Director states the volunteers will not be used at the day care until they meet all the licensing requirements. Director states will write the department a declaration with the detailed steps she will take to ensure volunteers are not used until they meet the requirements.
Type A
Section Cited
CCR
101216.3(a)
Teacher-Child Ratio
(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

2 unqualified volunteers were alone caring for day care children.
POC Due Date: 04/27/2026
Plan of Correction
1
2
3
4
Director states the volunteers will not be used at the day care until they meet all the licensing requirements. Director states will write the department a declaration with the detailed steps she will take to ensure volunteers are not used until they meet the requirements.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Reyes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2026 04:47 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 04/27/2026 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
1
2
3
4
Director states will have staff take the mandated reporter traning class and will email copies by the POC date.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above ] which poses/posed a potential health, safety or personal rights risk to persons in care.

2 volunteers that were observed alone with children do not have any immunization's on file.
POC Due Date: 05/08/2026
Plan of Correction
1
2
3
4
Director states will have the 2 volunteers obtain proof of MMR/TDAP/TB/FLU and send to the LPA by email by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Reyes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 04/27/2026 04:47 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 04/27/2026 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MT. CALVARY FAITH LUTHERAN PRESCHOOL & CHILD CARE
FACILITY NUMBER: 191593330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

2 volunteers do not have proof of a health screening report on file.
POC Due Date: 05/01/2026
Plan of Correction
1
2
3
4
Director states wil have staff obtained a signed and dated copy of their health screening report.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Reyes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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