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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300605642
Report Date: 12/02/2025
Date Signed: 12/02/2025 11:56:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2025 and conducted by Evaluator Dean Thompson
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20251110115214
FACILITY NAME:LUTHERAN CHURCH OF THE CROSSFACILITY NUMBER:
300605642
ADMINISTRATOR:SMITH, BRENDAFACILITY TYPE:
850
ADDRESS:24231 EL TORO ROADTELEPHONE:
(949) 581-8115
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:56CENSUS: 16DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brenda SmithTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Licensee is not properly addressing mold contamination at facility
Licensee allows day care children to use off limits bathroom
Licensee did not properly address playground hazard
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Thompson conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 11/14/2025. Upon arrival, LPA met with Director Brenda Smith, to deliver complaint findings. Director guided LPA on a tour of the facility. LPA observed a total of 16 children with three staff.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance with staffing ratios on today’s date. A review of the Facility Personnel Report Summary indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The Orange County Child Care Office received a complaint 11/10/2025, with three allegations (1) Licensee is not properly addressing mold contamination at facility, (2) Licensee allows day care children to use off limits bathroom, (3) Licensee did not properly address playground hazard.

Continue to Page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 06-CC-20251110115214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUTHERAN CHURCH OF THE CROSS
FACILITY NUMBER: 300605642
VISIT DATE: 12/02/2025
NARRATIVE
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During the investigation LPA interviewed three staff, interviewed four parents, and reviewed documents.

Reporting Party (RP) alleges Licensee is not properly addressing mold contamination at facility. The RP states that black mold was discovered in Room C, also known as the Twos room. The RP was asked by LPA if children were allowed inside Room C after discovering black mold was present and RP replied, “No the children were not allowed.” On 11/14/2025, LPA interviewed three staff. All staff interviewed stated children were not allowed inside Room C. On 11/14/2025, LPA was provided lab testing from LA Testing and inspection documents from SoCal Environmental. The report reads, “Based upon the visual inspection and the laboratory data, the airborne spore levels are within recommended guidelines” meaning that the concentration of mold spores in the air is considered normal and acceptable according to standard environmental health practices. On 11/14/2025, LPA toured the facility and observed Room C was closed due to repairs. Staff#1 (S1) stated Room C closed the day they were made aware of mold and Room C will reopen mid December or the beginning of the year in 2026.

On 11/21/2025, LPA contacted 12 parents via phone call. Four out of 12 parents were able to be interviewed. Parents interviewed did not divulge any information pertaining to the allegation.

Based on LPA observation, documents reviewed, interviews with staff and parents, there was not enough evidence to substantiate the allegation, Licensee is not properly addressing mold contamination at facility.

Reporting Party (RP) alleges Licensee allows day care children to use off limits bathroom. The RP stated that staff were instructed to allow two-year-old children to use the off-limits staff bathroom. On 11/14/2025, LPA interviewed three staff. Two out of three staff stated children were not using the off limit bathrooms, children were using the bathrooms located inside classrooms A and B which is on limits.

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SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 06-CC-20251110115214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUTHERAN CHURCH OF THE CROSS
FACILITY NUMBER: 300605642
VISIT DATE: 12/02/2025
NARRATIVE
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On 11/21/2025, LPA contacted 12 parents via phone call. Four out of 12 parents were able to be interviewed. Parents interviewed did not divulge any information pertaining to the allegation.

Based on interviews with staff and parents, there was not enough evidence to substantiate the allegation, Licensee allows day care children to use off limits bathroom.

Reporting Party (RP) alleges Licensee did not properly address playground hazard. RP mentioned, on 10/13/2025, a large branch fell near the building from the adjacent Laguna Woods golf course, and the tree was cut down later that week, during which all children were relocated to KidsBay. On 11/14/2025, LPA interviewed three staff. Staff interviewed stated the tree branch did not fall on the preschool building nor was the branch hanging over the preschool grounds. On 11/14/2025, LPA received pictures and photos reviewed did not show the tree branch on the preschool grounds. All staff stated Laguna Woods golf course had a company cut the tree the next day. One staff member mentioned closing classrooms out of precaution while the tree was being cut.

On 11/21/2025, LPA contacted 12 parents via phone call. Four out of 12 parents were able to be interviewed. Parents interviewed did not divulge any information pertaining to the allegation.

Based on photos received, interviews with staff, and parents, there was not enough evidence to substantiate the allegation, Licensee did not properly address playground hazard.

The Orange County Childcare Office has investigated the complaint alleging (1) Licensee is not properly addressing mold contamination at facility, (2) Licensee allows day care children to use off limits bathroom, (3) Licensee did not properly address playground hazard: although the allegations may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.


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SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 06-CC-20251110115214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUTHERAN CHURCH OF THE CROSS
FACILITY NUMBER: 300605642
VISIT DATE: 12/02/2025
NARRATIVE
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In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Exit interview conducted and report was reviewed with Director Brenda Smith.

The Director was provided a copy of their appeal rights LIC 9058 (03/22), and their signature on this form acknowledges receipt of these rights
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2025 and conducted by Evaluator Dean Thompson
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20251110115214

FACILITY NAME:LUTHERAN CHURCH OF THE CROSSFACILITY NUMBER:
300605642
ADMINISTRATOR:SMITH, BRENDAFACILITY TYPE:
850
ADDRESS:24231 EL TORO ROADTELEPHONE:
(949) 581-8115
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:30CENSUS: 16DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brenda SmithTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is not following reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Thompson conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 11/14/2025. Upon arrival, LPA met with Director Brenda Smith, to deliver complaint findings. Director guided LPA on a tour of the facility. LPA observed a total of 16 children with three staff.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance with staffing ratios on today’s date. A review of the Facility Personnel Report Summary indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The Orange County Child Care Office received a complaint 11/10/2025, with one allegation (1) Licensee is not following reporting requirements.

Continue to Page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 06-CC-20251110115214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUTHERAN CHURCH OF THE CROSS
FACILITY NUMBER: 300605642
VISIT DATE: 12/02/2025
NARRATIVE
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Page 2

During the investigation LPA interviewed three staff, interviewed four parents, and reviewed documents.

Reporting Party (RP) alleges Licensee is not following reporting requirements. RP mentioned the facility did not report black mold to licensing or parents. On 11/14/2025, LPA was informed by staff #1 (S1), the facility did not submit an unusual incident report (UIR) to licensing regarding the classroom closure for mold in room C. S1 mentioned classroom C was closed due to black mold. S1 provided LPA with records showing and email was sent out to parents informing them of the closure for classroom C due to a water leak.

On 11/21/2025, LPA contacted 12 parents via phone call. Four out of 12 parents were able to be interviewed. Parents interviewed did not divulge any information pertaining to the allegation.


Based on interview with S1 and S1 stating a UIR was not submitted to licensing, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter 12, is being cited on the attached LIC 9099 D for the deficiency sections 101212 Reporting Requirements (e) The items below shall be reported to the Department within 10 working days following their occurrence: (4) Any changes in the plan of operation that affect services to children.

In the areas that were evaluated, one Type B deficiency was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.



Exit interview conducted and report was reviewed with Director Brenda Smith.

The Director was provided a copy of their appeal rights LIC 9058 (03/22), and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 06-CC-20251110115214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUTHERAN CHURCH OF THE CROSS
FACILITY NUMBER: 300605642
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2025
Section Cited
CCR
101212(e)(4)
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101212 Reporting Requirements (e) The items below shall be reported to the Department within 10 working days following their occurrence: (4) Any changes in the plan of operation that affect services to children.

This requirement is not met as evidenced by:
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Director stated she will notify licensing of any incidents in the future.
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Based on interview with S1, the licensee did not comply with the section cited above. S1 stated a UIR was not submitted to licensing to notify the department of mold and closure of classroom C, which 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.
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7