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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600711
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:51:19 PM

Document Has Been Signed on 10/10/2023 01:51 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:NEWPORT HARBOR LUTHERAN CHURCHFACILITY NUMBER:
300600711
ADMINISTRATOR:MARTINEZ, TERRIFACILITY TYPE:
850
ADDRESS:798 DOVER DRIVETELEPHONE:
(949) 548-3631
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 88TOTAL ENROLLED CHILDREN: 86CENSUS: DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Velorie Mageean TIME COMPLETED:
02:00 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
On 10/10/2023 Licensing Program Analyst (LPA), A. Bootorabi conducted an on site visit for the purpose of a 1 year required inspection. LPA and Assistant Director Velorie Mageean toured the facility inside and outside. Upon arrival, an Entrance Checklist (LIC 125) was provided to Velorie Mageean Assistant Director.

Census was taken upon entry of each classroom:
Green Room 11 Children 1 Staff Blue Room 9 Children 1 Staff Red Room 10 Children 1 Staff
Pre-K Prep 12 Children 1 Staff Pre-K 1: 11 Children 1 Staff Pre - K2: 11 Children 1 Staff

During the inspection, it was determined the facility is operating within its licensed capacity and within compliance with staffing ratios. Facility hours were confirmed with the assistant director. The assistant director confirmed hours are 7:30 am - 5:30 pm Monday - Friday: School started August 16, 2023 - June 7 2024.

The LPA and assistant director toured the facility inside. Areas stated to be off-limits were made off-limits by means of closed doors, and gates.

Documents reviewed and to be posted in a prominent, publicly accessible area at the facility: Facility License, Waivers (if applicable), Menus, LIC 613A Personal Rights, PUB 269, PUB 393 Notification of Parent Rights, and LIC 610 Emergency Disaster Plan. Documents were posted in the Green Room and are not visible to the public.
A consultation was provided as only one classroom was observed to have documents posted in a visible area. The areas of drop off for the different classrooms did not have documents posted in a prominent, publicly area. Some classroom had Parent Rights, License and Emergency disaster plan by the entrance but not all required documents. PUB269 was not posted but correction was made during visit. Page 1
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
Documents to be reviewed during inspection: Verification of Disaster and Fire Drill, Daily Activity Schedule, Sign In/Out Sheets, and LIC 9148 Earthquake Preparedness. The facility had 4 of 4 documents available for review.
The last drill was conducted on 03/29/2023 (Fire Drill). The daily activity schedule was posted by in the Green Room The facility is using an electrical/ app to sign in and out. The assistant director stated that through the app the families can see the daily activity schedule the school follows. A copy was provided to LPA.
The facility representative was reminded:
(d) Disaster drills shall be conducted at least every six months.
(1) Completion of such drills shall not require travel away from the child care center grounds or contact with local disaster agencies.
(2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

CLASSROOMS: Classrooms 6 of 6 were toured with the assistant director. Classrooms 6 of 6 were inspected and the activity space, and items that could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children.

NAPPING EQUIPMENT: Mats are used for napping were observed to be maintained in a safe condition. The Admission Representative stated that families bring their own blankets from home and are stored in the classroom cubbies for each child.

The facility was reminded that napping equipment shall be arranged so that each child has access to a walkway without having to walk on or over the cots or mats of other children. Bedding shall not be shared by different children without first laundering the bedding. Bedding shall be individually stored so that each child's bedding is identifiable and no child's used bedding comes into contact with other bedding.

DRINKING WATER: Drinking water was observed and readily available to children in the classroom and LPA observed water jugs and cup.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
FOOD SERVICES: The facility does not provide meals to children. Children bring their meals from home. LPA observed children having a snack in playground #1.

IDENTIFICATION AND LOCATION OF MEDICATION STORED IN THE facility: The Assistant director stated that medication being stored in a locked box inside the kitchen and the Pre-K classroom upstairs have an individual office for each classroom that is used for storage of medication for children in that classroom.
The LPA reviewed the record of current medications, including the name of the prescribing physician, and instructions.
The facility was reminded:
(3)Prescription medications may be administered if all of the following conditions are met:
(A)Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.
(B)For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.
1.This documentation shall be kept in the child's record.
2.The instructions from the child's authorized representative shall not conflict with the label directions as prescribed by the child's physician.
(5)The licensee shall develop and implement a written plan to record the administration of prescription and nonprescription medications and to inform the child's authorized representative daily when such medications have been given.

(6)When no longer needed by the child, or when the child withdraws from the center, all medications shall be returned to the child's authorized representative or disposed of after an attempt to reach the authorized representative.

A copy of 101226 Health-Related Services and LIC PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS AND MEDICATION CHART was provided during today's inspection.

Page 3
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
Incidental Medical Services (IMS) - Child Care Centers

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies and reviewed children’s, personnel, and administrative records.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to the publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

CARBON MONOXIDE – SMOKE DETECTOR – FIRE EXTINGUISHER: A functioning carbon monoxide detector were tested by the assistant director during today’s visit and were observed to be functioning. A fire extinguisher was observed in one of the pre-k classroom and it was marked in full.

OUTDOOR ACTIVITY SPACE: The surface of the outdoor activity space was observed to be maintained in a safe condition for activities. The surface of the outdoor activity space was observed to be free of hazards including, but not limited to, holes, broken glass, and other debris.

The cushioning material used underneath the climbing structure in playground #1 consists of sand . The outdoor equipment and toys were in good repair and were free of sharp edges. There are no bodies of water present at the facility. The facility’s outdoor grounds are safe, sanitary, and in good repair. LPA observed sand toys, shade for children and storage for more toys outside.

The cushioning material used underneath the climbing structure in playground #2 consists of soft cushion material. The outdoor equipment and toys were in good repair and were free of sharp edges. There are no bodies of water present at the facility. The facility’s outdoor grounds are safe, sanitary, and in good repair. LPA observed balls, umbrella tables, bikes, and grass area.

Page 4
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
PERSONNEL RECORD REVIEW BEGAN AT 10:52 AM : The LPA requested to review staff records of adults working directly with children. The following documents were requested for review exemptions or exemptions, Staff Qualifications, Immunization Records, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to report Child Abuse, 1 CPR First Aid Certification of staff present at the facility at all times, TB clearance, and a Mandated Reporter Training Certificate.

The facility had one separate file for each staff member. The files reviewed during today’s visit were observed to be incompleted. There is at least one person certified in CPR & First Aide. All staff did not have a current Mandated Reporter Training.

The LPA reminded the facility representative:

(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.
and
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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.

The facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
Page 5
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
Children’s Records Review began at 11:17 pm : The LPA requested complete children’s records of 4 children enrolled in the program. Children's records were reviewed, and there was a separate, complete, and current record for each child. The LPA reviewed files to verify the following documents Immunization Records, LIC 700 Identification, Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. The children’s records are complete currently.

A consultation was provided on the following:
(B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.
1.This documentation shall be kept in the child's record.
2.The instructions from the child's authorized representative shall not conflict with the label directions as prescribed by the child's physician.
(5) The licensee shall develop and implement a written plan to record the administration of prescription and nonprescription medications and to inform the child's authorized representative daily when such medications have been given.
(6) When no longer needed by the child, or when the child withdraws from the center, all medications shall be returned to the child's authorized representative or disposed of after an attempt to reach the authorized representative.
A copy of 101226 Health-Related Services was provided during today's visit.
Review of records ended at 11:55 pm

Child Care Licensing Program Webinars: The Child Care Licensing Program is pleased to continue offeringwebinars to share important information with the childcare licensing community in 2023.
• Tuesday, December 12, 2023, 6:00 p.m.
To register for webinars, see Provider Information Notice (PIN), PIN 22-30-CCP.

The facility representative was informed of the www.MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
Safe Sleep: LPA discussed the safe sleep regulations with the licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 6 of 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
an additional resource. LPA also informed the licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1CCP).
A copy of lead sample was provided to the director MARTINEZ, TERRI. Who arrived around 11:55 am.
https://emsa.ca.gov/childcare_provider/ - was discussed

The facility did not meet the California Code of Regulations, Title 22 Division 12, and regulations not met were observed, discussed, and cited at the time of the visit.

The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today:
101174(d) , 101174(d), 101221(a), 101226(e)(3)(B)1
Notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the licensee the director MARTINEZ, TERRI and assistant director.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 7 of 20
Document Has Been Signed on 10/10/2023 01:51 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 10/10/2023 at 12:51 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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by means of not having a completed drill withing the last 6 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
1
2
3
4
The director stated she will be having the next drill conducted by Friday 10/13/2023. A statement of POC will be sent to the LPA via email.
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
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by means of having expired Mandated Reporter Training which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
1
2
3
4
The director stated staff will be working on completing the training by Monday. A statement will be sent to the LPA via email stating corrections have been made.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 8 of 20
Document Has Been Signed on 10/10/2023 01:51 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 10/10/2023 at 12:51 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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review , the licensee did not comply with the section cited above by means of having records from 2022 of children with no updates but having medication stored which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
1
2
3
4
The director stated she will be working on reviewing the files of the children and ensuring updates are occuring for children who need them. The director will send a statment to the LPA via email.
Type B
Section Cited
CCR
101226(e)(3)(B)1
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child. 1. This documentation shall be kept in the child's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by means of missing C2 not having the correct forms for medication stored in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
1
2
3
4
The director received a completed by parent via text during inspection. Moving forward the director stated she will be checking all medication and working on documentation for medications stored and administered.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


LIC809 (FAS) - (06/04)
Page: 9 of 20
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: NEWPORT HARBOR LUTHERAN CHURCH
FACILITY NUMBER: 300600711
VISIT DATE: 10/10/2023
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
Appeal Rights were explained. The Licensee 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 at the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817.

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/inspection-process
End of Report
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 20 of 20