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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:52:22 PM

Document Has Been Signed on 12/03/2024 01:52 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:SALEM LUTHERAN PRESCHOOLFACILITY NUMBER:
300602027
ADMINISTRATOR/
DIRECTOR:		BURNETT, JENNIFERFACILITY TYPE:
850
ADDRESS:6411 EAST FRANK LANETELEPHONE:
(714) 922-1067
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 75TOTAL ENROLLED CHILDREN: 80CENSUS: 22DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:DIrector-Jennifer BurnettTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 12/03/2024 at 12:10 p.m., a case management inspection was conducted today by Licensing Program Analyst (LPA), Navar who met with the Director, Jennifer Burnett. A self-reported incident by the facility was received at the regional office on 11/18/24 which stated that child #1 (C1) was left in a bathroom stall that is located in classroom A2 for about a minute without a staff member.

Upon arrival there were 8 staff members present and 22 children in care playing on the playground. A review of criminal record clearances 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 this investigation, LPA toured the facility with Director Jennifer and observed classroom A2 where bathroom is located, door connected to outside walkway leading to A5 classroom where Staff 2 (S2) was located, and playground area. LPA interviewed 3 staff (S1-S3) who were present at the time the incident happened and obtained a copy of children’s roster.

Based on the information gathered from the interviews conducted with S1-S3, observation and records reviews, it was determined that C1 was in the bathroom unsupervised for about 1-2 minutes at 3:45p.m. on 11/14/24 and that S2 was in classroom A5 and heard C1 crying and banging from the bathroom area and went to look. S2 saw C1 standing at a closed bathroom door leading to A2 classroom. C1 approached S2 and S2 walked back to their classroom and took C1 back to playground area and informed S3 that C1 was left in the bathroom, and they are back. S1-S3 stated that parent has been notified. S1 stated that they have changed their plan for taking children to the bathroom in the afternoon hours 3:30PM-6:00PM moving forward.

The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation Responsibility for Providing Care and Supervision section 101229(a)(1) was issued today on the attached LIC 809D. Continue to page 2.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SALEM LUTHERAN PRESCHOOL
FACILITY NUMBER: 300602027
VISIT DATE: 12/03/2024
NARRATIVE
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LPA Navar informed director Jennifer Burnett that this report dated 12/03/2024 for Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Navar informed the director Jennifer Burnett to provide a copy of this licensing report dated 12/03/2024 Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Jennifer Burnett. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights and deficiencies 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/03/2024 01:52 PM - It Cannot Be Edited


Created By: Karen Navar On 12/03/2024 at 01:30 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: SALEM LUTHERAN PRESCHOOL
FACILITY NUMBER: 300602027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2024
Section Cited
CCR
101229(a)(1)

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Care and Supervision 101229(a)(1): No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in ...

This requirement is not met as evidenced by:
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Director met with staff and had them sign stating they will follow new procedure when taking children to the bathroom from 3:30pm-6:00pm.
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Based on interviews conducted with S1-S3, it was determined that C1 was in classroom A2's bathroom unsupervised for about 1-2 minutes at 3:45p.m. on 11/14/24. As this poses as a health, safety, and personal rights risk to 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:Judy Hanson
LICENSING EVALUATOR NAME:Karen Navar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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