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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600010
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:54:24 PM

Document Has Been Signed on 05/17/2023 02:54 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:ABIDING SAVIOR LUTHERAN CHURCH & SCHOOLFACILITY NUMBER:
300600010
ADMINISTRATOR:WOLFINBARGER, MARYFACILITY TYPE:
850
ADDRESS:23262 EL TORO ROADTELEPHONE:
9498374292
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 85TOTAL ENROLLED CHILDREN: 85CENSUS: 76DATE:
05/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director, Mary WolfinbargerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Aiddee Nunez conducted an unannounced case management investigation for the incident which the facility self reported to licensing office on 5/10/2023. On 5/10/23 director called Community Care Licensing to report an unusual incident which according to the incident report, occurred at the facility on 05/09/23 at 11:55 am. Director stated as a teacher closed the door that's located next to the classroom's sink a child’s right hand pinky got jammed in the door while she was standing and waiting for her turn to wash her hands. The child’s right hand pinky finger was partially severed.

LPA toured the facility inside and outside and a census was taken as follow: 13 staff including director with 76 children. A review of staff criminal clearance records on this date indicates that all facility staff or other
individuals who require caregiver background checks have received criminal record and child abuse index
clearances or exemptions.

During today's inspection LPA Nunez reviewed files and interviewed 4 staff members including the director. The LPA also interviewed 1 parent. LPA tried to interview two children but was unsuccessful due to the age of the children. The children were 3 years of age.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ABIDING SAVIOR LUTHERAN CHURCH & SCHOOL
FACILITY NUMBER: 300600010
VISIT DATE: 05/17/2023
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Due to insufficient information available at this time, the above allegations needs further investigation.

An exit interview conducted with director. Appeal Rights were explained. The Director was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

End of report

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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