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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600010
Report Date: 07/20/2023
Date Signed: 07/21/2023 09:02:33 AM

Document Has Been Signed on 07/21/2023 09:02 AM - 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:
(949) 837-4292
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 85TOTAL ENROLLED CHILDREN: 85CENSUS: 35DATE:
07/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:The New Director, Celeste CisnaTIME COMPLETED:
05:00 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. LPA and the facility representative toured the facility inside and outside, and the floor and yard plan were verified. Census was taken in individual classrooms. The overall census observed was 35 preschool children with 6 preschool staff. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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 Child #1 (C1) right-hand pinky got jammed in the right side of the hinge-side of the door while she was standing next to the door that leads to the outside playground and it’s next to the sink, waiting for her turn to wash her hands as a teacher closed the door without knowing that the child’s right hand pinky finger was in the hinge-side of the door. The child’s right hand pinky finger was severely injured causing for the child to receive stiches.

On 5/17/2023 LPA Nunez interviewed 3 staff, the Director, (C1) parent, and (C1) about the incident that happened on 5/9/23 in classroom 103.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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: 07/20/2023
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On 5/31/2023 LPA interviewed Staff #5 (S5) via telephone. S5 was in the classroom on the day of the incident.

According to Staff# 3 (S3) on the day of the incident, S5 was changing Child #2 (C2) diaper when S5 was removing C2 diaper and shoes she noticed sand in C2’s shoes. S3 had just finished changing Child #4 (C4) diaper and offered to dump the sand outside. When S3 opened the door, she saw S4 outside in the playground and asked S4 if she can dump the sand out of the shoe. As S3 was closing the door C1 had her right pinky in the hinge-side of the door that is located next to the sink. S3 did not noticed and closed the door causing C1 to severely injure her right pinky.

S5 stated that she was in the classroom a few feet away from the sink that is next to the door where the incident happened but did not witness the incident.

On 9/21/22 another similar incident happen of C1 pitching her finger on the outside gate. While in care of the facility.

On 5/12/23 the facility has placed a door shield that prevents finger injuries on the inside hinge side of the door that is located next to the sink where the incident happened.


However, due to the severity of C1’s injury and from the information available to the LPA it is determined that the facility had violated Title 22 Regulation section 101229(a)(1) related to Supervision. The deficiency is being cited on the attached 809D.

This is a Type 'A' violation the Director shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file.

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

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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: 07/20/2023
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An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. The facility representative was informed that the '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. Failure to post Type A Reports for 30 days will result in a civil penalty of $100.00.

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

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2023 09:02 AM - It Cannot Be Edited


Created By: Aiddee Nunez On 07/20/2023 at 03:49 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ABIDING SAVIOR LUTHERAN CHURCH & SCHOOL
FACILITY NUMBER: 300600010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
HSC
101229j(a)(1)

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101229 Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child shall be left without the supervision of a teacher at any time,... Supervision shall include visual observation. This requirement is not met as evidenced by:
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On 5/12/23 the facility has placed a door shield that prevents finger injuries on the inside hinge side of the door that is located next to the sink where the incident happened and shilds where also placed on high traffic doors and gates areas. The new director stated she wil put door shields on every door in the facility by 7/21/23. The director will also provide a supervision training and provide a written statement of staff that attented and their signatures by the POC due date. The director will send the statement via email to the LPA.
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Based on LPA interviews, S3 failed to provide visual supervision for C1. There was absence of supervision when S3 closed the door and C1 had her finger inside of the hinge door which cause C1 to severely injure her right pinky. This poses an immediate Health and Safety risk to the children in care.
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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:Thuy Ho
LICENSING EVALUATOR NAME:Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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