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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020075
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:13:37 PM

Document Has Been Signed on 04/19/2022 02:13 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MT. CALVARY LUTHERAN PRESCHOOL AND DAY CAREFACILITY NUMBER:
198020075
ADMINISTRATOR:GEORGETTE DELGADOFACILITY TYPE:
830
ADDRESS:23300 GOLDEN SPRINGS DRTELEPHONE:
(909) 861-2740
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 20TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Janet Ramirez (Diaz)TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jennifer Hua conducted an unannounced Required - 1 year inspection. Upon arrival, LPA met with Janet Ramirez, teacher in charge. A COVID-19 risk assessment was conducted prior to entry to the facility. LPA provided Ms. Ramirez with a copy of the LIC 125 Entrance Checklist to facilitate the inspection. This is a preschool program. Facility also has a licensed Preschool Program #191503710. Business hours are from Monday-Friday, 6:30 AM to 6:00 PM. Per teacher, director is on vacation and will return next Monday.

LPA was guided to a facility tour by teacher in charge. All areas identified on the Facility Sketch were inspected. There are of total of 3 classrooms, and each room is divided into 2 rooms. LPA observed the following: 10 infants supervised by 4 staff.

The facility was observed to be within the license capacity and limitations. Children's roster was reviewed. Sign-In and Sign-Out sheets were reviewed.

Rooms identified on facility sketch were inspected Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Napping equipment and bedding were inspected. Storage for children's belongings. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed.

A first aid kit is kept in each classroom. Carbon monoxide detectors and smoke detectors are present in the facility. Fire extinguishers are serviced annually. Storage cabinet in classrooms was locked and hazardous items including cleaning compounds were stored inaccessible to children.

Report continues to next page
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL AND DAY CARE
FACILITY NUMBER: 198020075
VISIT DATE: 04/19/2022
NARRATIVE
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Outdoor equipment was inspected for safety, cushioning material, good repair and appropriateness. Required shade, drinking water and fencing were inspected. LPA informed Director that the infants need to be within the direct care and supervision, including visual supervision by the teacher(s) at all times. Infants use their own sippy-cups with their name written on the cups when outdoors. Play area was inspected for hazards and inaccessibility to bodies of water. No hazards observed.

Teacher-infant ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of infants are met and appropriate. Infant Needs and Assessments are done quarterly or updated as needed. Personal Rights of infants were observed by LPA. Staff and Infant Records were reviewed for completeness. Inspection of required forms made. Director stated there is a always a staff in the crib room when there is napping infant(s). During the walk, LPA observed a staff in the crib room supervising napping infants.

Staff and Children’s Records were reviewed. Criminal Record Clearances were reviewed for Associations and Transfers. Director and Staff are current on Pediatric First aid/ CPR as observed. Staff have required required Immunization and have completed the Mandated Reporting training.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm Per teacher no medication is provided at this time.

The following was discussed with the teacher:
Rooms that are off-limits need to be made inaccessible during operating hours. Smoking is prohibited. No infant walkers, no Johnny Jumpers, no excersaucers or any other item that falls into that category are allowed in facility. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your location.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MT. CALVARY LUTHERAN PRESCHOOL AND DAY CARE
FACILITY NUMBER: 198020075
VISIT DATE: 04/19/2022
NARRATIVE
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INFANT CARE: Appropriate sleeping arrangements and cribs is available/observed. (one crib for each infant in care is required). Cribs will not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their back for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and document the time of each 15-minutes. LIC 9227 Plan shall be completed for each infant up to 12 months of age. LPA provided the Director with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.

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 platform.To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. 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 tools, please send them by email 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/tion-process.

For forms, updates, Title 22 Regulations visit www.ccld.ca.gov

Deficiencies cited on attached 809D

Exit interview conducted and report was reviewed with teacher Janet Ramirez.



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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 04/19/2022 02:13 PM - It Cannot Be Edited


Created By: Jennifer Hua On 04/19/2022 at 01:41 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 LUTHERAN PRESCHOOL AND DAY CARE
FACILITY NUMBER: 198020075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

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
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4
Based on (record review)], the licensee did not comply with the section cited above. Staff #2 certificate expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Per teacher, will have staff and submit copy of certificate to LPA by POC due date of 4/29/2022
Type B
Section Cited
CCR
101415(c)
Infant Care Center Director Qualifications and Duties
(c) At least three of the semester or equivalent quarter units required in Sections 101215.1(h)(1)(B), (h)(2) and (h)(3) shall be related to the care of infants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above. Staff #3 transcripts does not indicate course which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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2
3
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Per teacher will submit copy of transcript/course description to LPA by the POC due date of 4/29/2022
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:Ana Chico
LICENSING EVALUATOR NAME:Jennifer Hua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/19/2022 02:13 PM - It Cannot Be Edited


Created By: Jennifer Hua On 04/19/2022 at 01:41 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 LUTHERAN PRESCHOOL AND DAY CARE
FACILITY NUMBER: 198020075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review)], the licensee did not comply with the section cited above. Infant #1 & #2 form was not completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Per teacher, will have form completed and submit copy to LPA by POC due date fo 4/29/22. Will also ensure form is completed for all infants under 12 months old.
Type B
Section Cited
CCR
101429(a)(2)(C)(3)
Responsibility for Providing Care and Supervision for Infants
(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: (3) Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview) (record review)], the licensee did not comply with the section cited above. Staff stated that napping infants are checked on but was not aware the need to document every 15 mintues that the napping infant is checked. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Per teacher, will create daily nap log so staff can document as required.
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:Ana Chico
LICENSING EVALUATOR NAME:Jennifer Hua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/19/2022 02:13 PM - It Cannot Be Edited


Created By: Jennifer Hua On 04/19/2022 at 01:41 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 LUTHERAN PRESCHOOL AND DAY CARE
FACILITY NUMBER: 198020075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(C)(4)
Responsibility for Providing Care and Supervision for Infants
(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: (4) Initials of person who conducted each check

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on (interview) (record review)], the licensee did not comply with the section cited above, nap check every 15 mintues is not documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Per teacher, will create nap log, so staff can document nap check every 15 minutes as required
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Jennifer Hua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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