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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418346
Report Date: 10/20/2021
Date Signed: 10/20/2021 06:06:31 PM

Document Has Been Signed on 10/20/2021 06:06 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BETHLEHEM LUTHERAN SCHOOLFACILITY NUMBER:
197418346
ADMINISTRATOR:FERRARA, TONIFACILITY TYPE:
850
ADDRESS:27265 LUTHER DRIVETELEPHONE:
(661) 251-6027
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 98TOTAL ENROLLED CHILDREN: 98CENSUS: 18DATE:
10/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:51 PM
MET WITH:Toni Engstrom(Ferrera)TIME COMPLETED:
06:00 PM
NARRATIVE
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On October 20, 2021 Licensing Program Analyst (LPAs) Liana Stepanyan along with LPA Lady King conducted a case management inspection on the above facility. LPAs met with the director Toni Engstrom(Ferrera), who informed LPAs staff #1 has be working for the center for 3 month monday thru Friday 9:00AM to 3:00 PM. LPAs did not observed staff #1 to be associated on the current roster. LPA asked director for a copy of the the current Child Care Facility Roster.

From the information gathered the facility is being cited for the above violation according to Title 22 Regulations.

see LIC 809D for deficiency
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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 10/20/2021 06:06 PM - It Cannot Be Edited


Created By: Liana Stepanyan On 10/20/2021 at 05:06 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: BETHLEHEM LUTHERAN SCHOOL
FACILITY NUMBER: 197418346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2021
Section Cited
CCR
101170(e)(2)

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101170 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 101170(f) This requirement was not met as
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Director stated she will email a request to transfer criminal record to assigned LPAs by POC date. Criminal Background Clearance Transfer Request LIC 9182
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 evidence by: LPAs did not observe staff #1 assoicated to the facility on 10/20/21
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Type B
10/22/2021
Section Cited
HSC1596.841

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Health and Safety Code Section 1596.841 requires that each child care facility
maintain a current roster of children who are provided care in the facility. The roster
shall include the child’s name, address, names and day phone numbers of the
parent(s) or guardian(s) and name and phone number of the child’s physician. This is
an optional form that may be used for this purpose.
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Director will email a current roast by POC date.
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This requirement was not met as evidence by LPAs did not receive a current Child Care Facility Roster
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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:Mariela Ramon
LICENSING EVALUATOR NAME:Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
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