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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197414470
Report Date: 04/09/2025
Date Signed: 04/09/2025 04:41:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2025 and conducted by Evaluator Tatiana Bickham
PUBLIC
COMPLAINT CONTROL NUMBER: 58-CC-20250403093229
FACILITY NAME:SHEPHERD OF THE VALLEY LUTHERAN CHURCHFACILITY NUMBER:
197414470
ADMINISTRATOR:SUZANNE LEGUMFACILITY TYPE:
850
ADDRESS:23838 KITTRIDGE STREETTELEPHONE:
(818) 347-6784
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:104CENSUS: 30DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Season Eng, DirectorTIME COMPLETED:
04:41 PM
ALLEGATION(S):
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Licensee is allowing unqualified staff to provide care to day care children.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced complaint inspection on 4/9/2025 at 12:30 PM. Upon arrival, LPA met with Administrator, Wendy Torres and was later joined by Director Season Eng and explained the purpose of the visit. There were seven (30) children and 9 staff were observed at the time of visit.

During the course of the investigation, interviews were conducted and copies of Staff roster were obtained and reviewed. LPA also reviwed staff files.

Per Reporting Party, Licensee is allowing unqualified staff to provide care to day care children.

Per interview with Administrator, when staff are hired they are interviewed, transcripts and references are reviewed prior to hire.
Page 1.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 5
Control Number 58-CC-20250403093229
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SHEPHERD OF THE VALLEY LUTHERAN CHURCH
FACILITY NUMBER: 197414470
VISIT DATE: 04/09/2025
NARRATIVE
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Per interview with Director, the Administrator will talk to the applicants over the phone then the applicant will come in for an interview. Transcripts and course descriptions are reviewed and applicant interactions are reviewed prior to hire.

LPA reviewed 9 staff files. Out of 9 staff LPA was only able to qualify 5. There are 4 full qualified teachers with 12 units or more, 1 qualified teacher with 6 units, 1 teacher LPA was only able to verify 1 qualified course, 1 teacher LPA was unable to qualify their education based off of the course titles listed on their transcripts, only 1 of 2 toddler teachers have infant/toddler units, and 2 teachers are missing transcripts LPA unable to verify their qualifications.

Based on LPA’s observations and file reviews, the allegation of Licensee is allowing unqualified staff to provide care to day care children is Substantiated. Meaning the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), are being cited on the attached LIC 9099D.

Exit interview was conducted with Director Season Eng. Appeals Rights and the Notice of Site visit were provided. The Notice of Site Visit must remain posted for 30 days during the hours of operation. Failure to maintain posting as required will result in a civil penalty of $100.00.

Page 2.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 58-CC-20250403093229
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SHEPHERD OF THE VALLEY LUTHERAN CHURCH
FACILITY NUMBER: 197414470
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2025
Section Cited
CCR
101216.1(b)(1)
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(b) Prior to employment, a teacher shall meet the requirements...(1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent quarter units of the education requirement...
This requirement was not met as evidenced
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Director will provide a copy of the transcripts for the staff and will obtain course descriptions for the required courses.
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by LPA observations and file review. LPA was unable to verify qualifitions for 4 teachers. This poses an potential health and safety risk to 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.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5