198006310-8-21-2025-54-CC-RDEO-DKRUBC-20250821152606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198006310
Report Date: 08/21/2025
Date Signed: 08/21/2025 03:26:28 PM

Document Has Been Signed on 08/21/2025 03:26 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. PAUL'S LUTHERAN CHURCH & PRESCHOOL		FACILITY NUMBER:	198006310
ADMINISTRATOR/ DIRECTOR:	RACHEL PETERSON		FACILITY TYPE:	850
ADDRESS:	2283 PALO VERDE AVENUE		TELEPHONE:	(562) 598-4729
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 69	TOTAL ENROLLED CHILDREN: 45	CENSUS: 42	DATE:	08/21/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:10 AM
MET WITH:	Director - Rachel Peterson		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Randy Derraco conducted an unannounced annual inspection on 08/21/25 at 11:10 am. LPA met with Rachel Peterson, Director, who guided analyst on a tour of the facility. This is a preschool program which consists of 3 classrooms. Facility operation hours are Monday to Friday from 7:00 AM to 6:00 PM. All areas identified on this report were inspected. Upon arrival, the following staff were present during this inspection: Blue Room: Staff S6, S7, and S8 with 16 children; Yellow Room: Staff S1 and S5 with 12 children; Green Room: Staff S2 and S3 with 14 children. Teacher-child ratios were observed to be in accordance with Title 22 Regulations. All children were observed to be under visual supervision of a teacher at all times. The following was observed during the tour of the facility: Children's roster was reviewed and is current. Per Director, the center uses the Procare application for authorization representatives to sign in and sign out their respective child. Children present were signed in. Disaster drill log was available. LPA observed required licensing documents posted on bulletin board in the main office. Furniture and equipment were inspected for age appropriateness and good repair. LPA observed material and equipment are free of sharp, loose, or pointed parts. Telephone service, heating, lighting and ventilation were evaluated and are operable. Children have their own cubby to store their belongings. Linens are taken home each Friday to be washed and returned on the following Monday. LPA observed that

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Randy Derraco
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

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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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. PAUL'S LUTHERAN CHURCH & PRESCHOOL	FACILITY NUMBER: 198006310
	VISIT DATE: 08/21/2025

NARRATIVE

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the center has spare linens stored in a cabinet in case a child forgets to bring back their linens. Napping equipment (cots) were observed in separate storage areas. Per Director, the isolation area is located in the office. Age appropriate sinks and toilets were inspected for availability and good repair in all restrooms. General sanitation was observed.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were made inaccessible to children. According to the Director, medication is only administered to a child when accompanied with a doctor's note. Medication is stored in the child's classroom in a locked cabinet where it is inaccessible to children in care. Currently, there are no children in care the require prescription medication. Director understands that storage areas for poisons must be locked with a key or combination lock. Per Director, cleaning supplies are stored in a locked closet in the bathroom. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. First Aid supplies were observed in the classroom.

Menus were reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative. The facility provides two snacks and a hot lunch. Per Director, hot lunch is only served on Mondays, Wednesdays, and Fridays. Children bring food from home on Tuesdays and Thursdays. Children also have an option of bring lunch from home for the entire week. LPA observed that lunch containers are individually labeled and properly stored or refrigerated. LPA observed that water is readily available indoors via water jugs. Water jugs are filled from the sinks throughout the center and filtered using a Brita Filtration system. Water bottles are also brought from home and filled as needed by the center's staff. Water cups are available for children to use.

All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins have tight-fitting covers that are kept on, and in good repair. All foods/beverages are stored in covered containers at 45˚ (F) or less.

Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space is maintained in a safe condition as is free of hazards. Areas around and/or under climbing equipment, swings and slides have cushioning material to absorb a fall. The outdoor area has adequate shade. LPA observed that water is readily available outdoors via water jugs that are brought outside

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Randy Derraco
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. PAUL'S LUTHERAN CHURCH & PRESCHOOL	FACILITY NUMBER: 198006310
	VISIT DATE: 08/21/2025

NARRATIVE

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from the classroom. The Director states that there are no bodies of water on the premises and LPA did not observe any bodies of water during this visit. Director states there are no weapons or firearms on the premises.

LPA observed that S1 has a "pending" status on their criminal background clearance. LPA advised Director that a citation under Health and Safety Code (HSC) Section 1596.871(c)(1)(A) will be issued. There is at least one person trained in CPR and Pediatric First Aid present during this inspection.

Children’s and Staff’s Records were reviewed and are complete.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 are available at: https://www.ada.gov/resources/child-care-centers

LPA advised the Director to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov.

LPA R. Derraco informed Director that this report dated 08/21/25 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA R. Derraco informed the Director to provide a copy of this licensing report dated 08/21/25 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 from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

Exit interview conducted and report was reviewed with Director, Rachel Peterson.

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Randy Derraco
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/21/2025 03:26 PM - It Cannot Be Edited

Created By: Randy Derraco On 08/21/2025 at 03:05 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. PAUL'S LUTHERAN CHURCH & PRESCHOOL	FACILITY NUMBER: 198006310
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

HSC

1596.871(c)(1)(A)

(c) (1) (A) 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. A person specified in subdivision (b) who is not exempt from fingerprinting shall be fingerprinted... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interivew, S1 did not obatin criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2025
	Plan of Correction
1 2 3 4	POC Visit

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.

	Denise Gibbs
NAME OF LICENSING PROGRAM MANAGER:

	Randy Derraco
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC809 (FAS) - (06/04)

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