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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300604497
Report Date: 04/29/2025
Date Signed: 04/29/2025 01:56:06 PM

Document Has Been Signed on 04/29/2025 01:56 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CHRIST LUTHERAN PRESCHOOLFACILITY NUMBER:
300604497
ADMINISTRATOR/
DIRECTOR:		EMILY MARTINEZFACILITY TYPE:
850
ADDRESS:760 VICTORIA STREETTELEPHONE:
(949) 631-1639
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 129TOTAL ENROLLED CHILDREN: 129CENSUS: 108DATE:
04/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Director Emily MartinezTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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(Page 1)

Licensing program analysts (LPAs) Giselle Lucero and Kathy Trinh conducted a Case Management visit, on today's date 04/29/2025. The purpose of today's visit is due to deficiencies that were observed during an unusual incident report (UIR) that was reported by the facility on 04/09/2025.

The facility reported the ratio on the date of the incident to be 13 toddlers to 3 staff in Room #107. It was observed the facility is currently licensed for a capacity of 7 toddlers in the “New Nursey/Pink Room #117” only.

LPAs met with Director Emily Martinez. Upon arrival LPAs toured the facility and census was taken. LPAs observed 12 toddler children with 3 staff in the Toddler room/Room #107 and a total of 96 preschool children with 12 staff in the play yard and classrooms (Orange Stars/Room#116, Purple Stars/Room #108, Red Stars/Room# 109, Blue Stars/Room #110, Yellow Stars/ Room#115, Green Stars/ Room #111).

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 interview with Director, Director stated Room #107 had been previously licensed under the preschool license and they were previously licensed for 12 toddler children. Director was unaware a fire clearance approval, and the Department’s approval is needed to be obtained for toddler usage in Yellow Stars/Room #107 before moving the toddler class in that room and was unaware of the decrease in the toddler capacity.


(continue to page 2)
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/29/2025 01:56 PM - It Cannot Be Edited


Created By: Giselle Lucero On 04/29/2025 at 12:02 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: CHRIST LUTHERAN PRESCHOOL
FACILITY NUMBER: 300604497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2025
Section Cited
CCR
101161(a)

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101161 Limitations on Capacity (a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation. This requirement was not met: Based on observations, interview and..
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Director stated they will obtain parents/guardian's consent to move children 2 years and older to the preschool classroom. Director stated there are currently 5 toddlers between the age of 18-36 months; toddlers will be moved back
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file review, it has been determined the facility is over capacity. Facility is only licensed for 7 toddler and there are currently 13 toddlers enrolled and attending. This poses/posed an immediate health, safety or personal rights risk to persons in care.
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into Room #117 by POC due date.

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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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/29/2025 01:56 PM - It Cannot Be Edited


Created By: Giselle Lucero On 04/29/2025 at 12:12 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: CHRIST LUTHERAN PRESCHOOL
FACILITY NUMBER: 300604497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
CCR
101237(a)

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101237 (a) Alterations to Existing Buildings or New Facilities …Prior to construction or alterations, the licensee shall notify the Department of the proposed change(s). Based on observations, interview and file review, it has been determined the facility is using a classroom that is not licensed for
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Director stated toddlers 18-36 months will be moved out of the classroom and back to the original licensed room. Director also stated an application will be submitted to request usage of room #107 for their toddler component by POC due date.
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toddlers. This poses/posed a potential health, safety or personal rights risk to persons 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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL
FACILITY NUMBER: 300604497
VISIT DATE: 04/29/2025
NARRATIVE
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(Page 2)

Based on LPA's observation, interview and file review, the licensee did not comply with the section cited above. The facility is currently licensed for a capacity of 7 toddlers in the New Nursery/Pink room/ #117 only, based on today's visit, the facility is conducting in Room #107 for their toddler component with 13 toddlers currently enrolled and attending. It has been determined the facility is in violation of the Limitations on Capacity 101161 (a) and the Alterations to Existing Buildings or New Facilities 101237(a); and is being cited on the attached LIC 809Ds.

LPA Lucero informed Director that this report dated 04/29/2025 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Lucero informed Director to provide a copy of this licensing report dated 04/29/2025 that documents any Type A citation(s) 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 Emily Martinez. A notice of site visit was given and must remain posted for 30 days. Appeal Rights and deficiencies were discussed.

End of report.
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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