300604497-8-4-2022-06-CC-KDEI-CGZ33K-20220804175340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300604497
Report Date: 08/04/2022
Date Signed: 08/04/2022 05:53:52 PM

Document Has Been Signed on 08/04/2022 05:53 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:	CHRIST LUTHERAN PRESCHOOL		FACILITY NUMBER:	300604497
ADMINISTRATOR:	LISA HOLLOWAY		FACILITY TYPE:	850
ADDRESS:	760 VICTORIA STREET		TELEPHONE:	(949) 631-1639
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY: 134	TOTAL ENROLLED CHILDREN: 134	CENSUS: 58	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Ms. Holloway, Lisa		TIME COMPLETED:	06:15 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) Desai, Ketki conducted an on site inspection for the purpose of a 1 year required annual Inspection and a Case Management (Change in rooms for the toddler option children) as facility has requested an addition of a new Toddler room (Nursery) and the current Toddler classroom # 115 will be used by Pre-school children and Pre-school Room # 107 shall be removed from the Pre-School License. LPA and facility representative Ms. Holloway, Lisa toured the facility inside and outside, and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 53 Preschool age children with 5 Toddlers option children with 9 staff (2 in toddler room and 7 in Preschool rooms). Only children enrolled in Summer camp were present on campus. Facility has Toddler option with Preschool license. Toddler room and yard is separate from Preschool classrooms. Age appropriate furniture and equipment's were observed in this room. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. Facility hours are 6.30 am- 6:30 pm, Monday through Friday. 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. During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Children bring in their own lunch and snacks. Additional snacks are available in the facility. Floors, equipment, and furniture were clean and observed to be in good repair and free of sharp edges. There is drinking water available to children indoors. The children's bathrooms are clean and sanitary. Children nap on cots, bedding is stored individually and is taken home weekly to be washed by parents. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300604497
	VISIT DATE: 08/04/2022

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The facility has conducted an emergency drill within the past six months and keeps documentation of drills. The facility has at least one working smoke detector, one working carbon monoxide detector and at least one functioning fire extinguisher. Facility meets all posting requirements. The outdoor activity space was inspected for compliance.
The playground is enclosed by a fence at least four feet in height and is in good repair. Toddler yard is separate from the preschool yard. There is sufficient shade in each yard.

The surface of the outdoor activity space is maintained and free of hazards. The cushioning material around outdoor play equipment and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided with personal water bottles and water pitcher. The outdoor equipment and toys are in good repair and free of sharp edges. There are no bodies of water present at the facility.

The inspected outdoor facility grounds are safe, sanitary and in good repair. Staff files were reviewed for staff present during the facility inspection on this date.
On today's inspection, facility is adding a new classroom to the Toddler option program. New Toddler room (Nursery) was measured.

Currently facility is licensed for 122 preschool age children with 12 Toddler option children in the seven assigned classrooms, with a total capacity of 134 children.

Now facility is swapping one classroom Room # 115 to the preschool program, adding new Toddler option classroom (Nursery) and removing Room # 107 from the Preschool license. Overall capacity remains at 134.

New Toddler option classroom was observed to have the following:
· Classroom is adequately equipped with age and size appropriate furniture and equipment
· Drinking water is available inside through water pitchers with disposable cups and personal water bottles
· Sign in/Sign out procedure was reviewed and meets regulation requirements (Electronic sign in and out)
· There is a working smoke detector, carbon monoxide detector and fire extinguisher that meet statutory requirements.
· Cubbies available for storage of individual child’s personal belongings and/or bedding
· Napping equipment: Cots are used and are stored at the end of the classroom, napping linens are provided by the facility and blankets are brought from home. (2) Continued

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300604497
	VISIT DATE: 08/04/2022

NARRATIVE

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There is one toilet and three sinks in the classroom for the Toddler option children including one potty chair.
Changing table is at the arm's length next to the sink inside the bathroom.
Age appropriate activities are arranged for Toddlers in this room.

LPA measured the new Toddler option room (Nursery) on today's inspection
Indoor activity space for Toddler option room (Nursery) : 236'03 divided by 35 = 6.74 ( 7 Toddlers)

The new Toddler option room can accommodate only 7 Toddlers. Facility does not have sufficient space to occupy the requested capacity for 12 Toddlers.

Toddler room has 1 toilet , 1 Potty chair and 3 sinks including a changing table within arm's length.

Outdoor Activity for Toddler option: Facility has a designated Toddler yard shared with younger preschool age children and Waiver is in place. The Toddler yard is completely fenced, has age appropriate
outdoor activity structures . Structures are placed on a soft cushion material to absorb the falls and there is a concrete area surrounding the fence used as a Bike trail. Artificial turf is also placed on the play yard. Sufficient shade is provide by Easy pull up tents and a Sail along with the shade from the building roof line.

Toddler yard : 3746'25 divided by 75= 49'95 ( 50 children)
Facility has sufficient yard space to accommodate 7 toddlers in the designated yard.

Based on the indoor and outdoor measurements, sink and toilet availability, facility has enough space to accommodate only 7 Toddler option children in new Toddler room (Nursery) along with 122 Preschool age children (2-6 years old) in the assigned six rooms. Total capacity of 129 children.

Fire clearance received from Costa Mesa Fire Prevention office have approved the requested capacity.

Facility Administrator is current on the required Immunization/ Pediatric CPR/ First training valid through 8/23/2023 and have provided the completion certificate for the Preventive Health training (Nutrition and Lead component and Mandated Reporter training certificate

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300604497
	VISIT DATE: 08/04/2022

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LPA reviewed the following during the Exit Interview with the Facility Director Ms. Holloway, Lisa

Criminal Record Statement: Facility Representative Ms.Holloway, Lisa was was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Safe Sleep :

LPA discussed the safe sleep regulations with facility representative Holloway, Lisa and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative Holloway, Lisa 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.

Incidental Medical Services (IMS)

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Review of records to be maintained

LPA reviewed with facility representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300604497
	VISIT DATE: 08/04/2022

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Subscribe to CCLD important information

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Notice of Site Visit

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

A new license with a total capacity of 129 children: Monday -Friday (6.30 am to 6:30pm )

122 Preschool age children (2-6 years old) in Preschool room # 108,109,110,111,115 and 116

7: Toddler option children (18-36 months ) in toddler room (Nursery) .

Waiver for Shared yard: Toddlers and Younger Preschool age children.

LPA reviewed 6 Children's file and 5 Staff file during the annual inspection.

Exit interview conducted with the Facility Representative Ms. Holloway, Lisa

No deficiencies were cited on today's inspection.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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