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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602390
Report Date: 07/18/2022
Date Signed: 07/18/2022 03:26:54 PM

Document Has Been Signed on 07/18/2022 03:26 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MESSIAH LUTHERAN PRESCHOOLFACILITY NUMBER:
300602390
ADMINISTRATOR:SWANSON, DONNAFACILITY TYPE:
850
ADDRESS:4861 LIVERPOOLTELEPHONE:
(714) 528-8632
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 129TOTAL ENROLLED CHILDREN: 129CENSUS: 0DATE:
07/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Donna Swanson, DirectorTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stacy Torrence conducted an unannounced Case Management visit. LPA met with Donna Swanson, Director, to discuss the Lead Sampling Testing conducted on 06/10/2022. Director was advised on 07/13/2022 that the Lead Sample Report was to be posted. LPA confirmed that Director had posted the Lead Sample Report.

Director stated the drinking faucet/outlet with the high level of Lead is located in classrooms 101, 121, and 123, have been replaced and scheduled for retesting on 07/29/2022. Director also stated all the faucets in the facility has been replaced. Director stated the facility is closed for the summer and scheduled to reopen on 07/25/2022.

Based on LPAs record reviews the following violation was observed and is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 3, Section 101238(a) Buildings and Grounds is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the facility representative Donna Swanson. A notice of site visit was given and must remain posted for 30 days.



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 to the address listed above.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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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Document Has Been Signed on 07/18/2022 03:26 PM - It Cannot Be Edited


Created By: Stacy Torrence On 07/18/2022 at 03:13 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: MESSIAH LUTHERAN PRESCHOOL
FACILITY NUMBER: 300602390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2022
Section Cited
CCR
101238(a)

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101238(a) Buildings and Grounds. The childcare center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children; employees and visitors. This requirement was not met as evidenced by:
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Director posted the lead sampling test results and the faucets/outlets have already been replaced and is scheduled for retesting on 07/29/2022, and a sign indicating "Not In Use” was also posted.
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Based on facility Lead sampling tests it was discovered that drinking faucet/outlet in classrooms 101, 121, and 123 had high level of lead. This poses a potential risk to the health of 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:Stacy Torrence
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022


LIC809 (FAS) - (06/04)
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