<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600175
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:25:07 PM

Document Has Been Signed on 04/17/2024 12:25 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:OUR SAVIOR'S LUTHERAN PRESCHOOLFACILITY NUMBER:
300600175
ADMINISTRATOR/
DIRECTOR:		RIVAS, AMYFACILITY TYPE:
850
ADDRESS:200 SAN PABLOTELEPHONE:
(949) 492-6165
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 116TOTAL ENROLLED CHILDREN: 116CENSUS: 50DATE:
04/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Amy Rivas, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:45 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) Tran and LPA Castro conducted a case management inspection to follow up on a self-report unusual incident that was submitted to CCL Regional Licensing Office on 03/29/2024. It was reported by Amy Rivas, Director via fax at 2pm. According to the Director, the unusual incident occurred on 03/28/2024 at approximately 10:30am. Mrs. Rivas stated the following: Staff #1 (S1) took students to the restroom outside on the playground, when S1 went to go back to class, S1 did not take head count and locked the bathroom door. Within 2-3 minutes later, Staff #2 (S2) was standing outside in the playground and heard Child #1 (C1) crying and let C1 out of the restroom, S2 unlocked the restroom's door and took C1 back to class. S1 informed C1's parents of the incident.

During today's inspection a tour of the facility was conducted and census was taken: LPAs observed 13 children on the playground at the time of arrival with 2 teachers from classrooms #2 and #3, 10 children with 1 teacher in classroom # 4, 6 children with 1 teacher in classroom #6, 11 children with 2 teachers in classroom #7 and 10 children with 1 teacher in classroom #8. During today's inspection, the facility was observed operating within its licensed capacity and within compliance of staff to child ratios. A review of staff 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. During today's inspection, staff members were interviewed.

All interviewed staff and Director confirmed that incident did occur on 03/28/24 as reported, and C1 was in the locked restroom alone for a brief moment approximately 2-10 minutes. Deficiency regarding lack of supervision was found.

(Continue next page)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 300600175
VISIT DATE: 04/17/2024
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
26
27
28
29
30
31
32
(Page 2 of Report)

Based on LPA’s interviews conducted with four staff, the following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101229(a)(1) Responsibility for Providing Care and Supervision. The deficiency is being cited on the attached 809D.

Due to the Type 'A' violation the licensee 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.

Appeal Rights and deficiency 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 Regional Office within 15 business days. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director Amy Rivas.

(End of Report)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/17/2024 12:25 PM - It Cannot Be Edited


Created By: Nguyen K Tran On 04/17/2024 at 12:02 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: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 300600175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time...
This requirement is not met evidenced by:
1
2
3
4
5
6
7
Director states she will submit a detailed plan to ensure all children are being supervised at all time including transitioning from the classroom to the restroom and vice versa, to LPA by due date.
8
9
10
11
12
13
14
Based on LPA's interviews conducted with 4 staff, all interviewd staff confirmed that C1 was left alone in the locked restroom for approximately 2-10 minutes, which posed an immediate risk to the health, safety and personal rights of the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Martha Malane
LICENSING EVALUATOR NAME:Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3