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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600175
Report Date: 05/15/2024
Date Signed: 05/15/2024 09:39:24 AM

Document Has Been Signed on 05/15/2024 09:39 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: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: 24DATE:
05/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Brittany PaepkeTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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On 5/14/2024, at 8:30 AM, Licensing Program Analyst (LPA) Dean Thompson conducted an unannounced Case Management inspection. LPA toured the facility and met with Administrative Assistant Brittany Paepke and advised Brittany the purpose of the inspection. LPA was provided a tour of the facility. There were 24 preschool age children in care with 6 staff at the time of the inspection.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing 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 5/6/2024, Director Amy Rivas contacted Community Care Licensing (CCL) to self-report an incident of child-on-child inappropriate interaction. On 5/2/2024, during bath time, parent #1 (P1) observed child #1 (C1) with purple markings on the genitals and between the buttocks.

On 5/6/2024, per the self reported incident submitted, staff #2 mentioned they were unsure if the incident happened at all but was going off of the information provided by C1.

On 5/7/2024, LPA contacted P1 via phone call. P1 agreed to provide LPA with additional information pertaining to the incident. LPA did not receive the information requested from P1. LPA followed up with P1 via email as well as phone calls and did not get a response.

On 5/15/2024, LPA interviewed staff #1 (S1). S1 stated they did not see the incident occur and was made aware of the incident from S2.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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: OUR SAVIOR'S LUTHERAN PRESCHOOL
FACILITY NUMBER: 300600175
VISIT DATE: 05/15/2024
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Based on the information provided on the self reported incident and interview with S1, there was not enough evidence to determine if the incident occurred at the facility.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Exit interview conducted and report was reviewed with Brittany Paepke. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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