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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418346
Report Date: 11/15/2024
Date Signed: 11/18/2024 02:21:13 PM

Document Has Been Signed on 11/18/2024 02:21 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BETHLEHEM LUTHERAN SCHOOLFACILITY NUMBER:
197418346
ADMINISTRATOR/
DIRECTOR:		RICK TERWALLFACILITY TYPE:
850
ADDRESS:27265 LUTHER DRIVETELEPHONE:
(661) 251-6027
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 98TOTAL ENROLLED CHILDREN: 98CENSUS: 29DATE:
11/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Director Marsha MacIntyreTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On November 15, 2024 at 1:30pm Licensing Program Analyst (LPA) Alemoh, met with facility Director Marsha to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted on to the Department on November 4th, 2024. The unusual incident report was regarding a supervision incident involving child 1. Upon arrival, there were 29 children and 4 staff present at the facility.

During this inspection, interviews were conducted with the Director and staff. In addition, LPA reviewed staff and children files. Furthermore, LPA also completed a safety inspection of the play yard area.

Based on interviews and record review, it was determined that C1 was left unattended in the play yard area during transitioning for an undetermined amount of time. Director stated that adult #1(A1) noticed C1 was unsupervised in the play yard area. A1 brought the child to the church administration and informed them of the incident to which the church admin brought the child to the Center Director. The incident occurred while all other children and all teacher were in inside the classroom.



A total of 34 children and 6 staff members were present when the incident occurred. After the incident the Director spoke with S1 regarding the incident. Based on confidential interviews, C1 was observed in the barricaded outdoor play area unsupervised. The area C1 was left unattended is secured and C1 did not leave the premises. Although the management took appropriate action, the care and supervision violation did occur.

A deficiency is being cited based on interviews, in accordance with California Code of Regulations, Title 22, see LIC 809D.

An exit interview was conducted, where the plan of correction was reviewed and developed with Marsha Maclintyre. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with facility representative Marsha MacIntyre.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Andrew Alemoh
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 11/18/2024 02:21 PM - It Cannot Be Edited


Created By: Andrew Alemoh On 11/15/2024 at 02:01 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
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Per director statements she will be conducting a staff meeting on 11/22/2024. LPA informed director to send a copy of the staff meeting agenda along with the sign in sheet of all the staff members attending the meeting no later than the due date of 11/22/2024.

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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:Andrew Alemoh
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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