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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371523
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:44:52 PM

Document Has Been Signed on 10/21/2021 03:44 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:CROSSLINE CHRISTIAN PRESCHOOLFACILITY NUMBER:
304371523
ADMINISTRATOR:STARK, MICHELEFACILITY TYPE:
830
ADDRESS:23331 MOULTON PKWY.TELEPHONE:
(714) 646-4265
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 0DATE:
10/21/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Facility Administrator Ms. Stark , Michele and Church Representative Ms. Carrasco, MarciTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ms. Ketki Desai conducted an announced on site pre-licensing inspection at the childcare center. It is a New facility and Facility Administrator Ms. Stark , Michele and Church Representative Ms. Carrasco, Marci who gave a tour of the Child Care Center.
The applicant has requested to provide care and supervision for 16 Infants (6 weeks to 24 months) and 12 Toddlers, (18 months to 36 months) (Infant Toddler component) Monday through Friday 7:00 AM-6:00PM (Full day session ) and 8:00 AM -12:00PM (Half day session) in the assigned Two Infant classrooms # 1 & 2 and one Toddler classroom # 3.
Due to COVID 19, LPA observed representatives wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines. Parents shall be encouraged to follow the CDC and COVID requirements, children shall be received at the entrance door by the staff, temperatures will be checked, hands sanitized before they are taken to their classrooms. Parents shall sign them electronically.

A review of the Facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is located on the Church grounds (Education center building) there is parking lot in front of the building, parents shall access the building with two entrance gates, parents with younger infants shall access the gate on the lower level while older children parents shall walk up the steps to the lobby area to gain access to the classroom. Sign in procedure is a digital application where parents can use the phones and as well as I-Pads, which are placed in each room for electronic sign in's.

There are two levels in the Education center building: first level has two assigned Infant rooms # 1 and 2 , while Toddler room is in Room # 3. There is a small infant yard adjoining room # 1. (Page-1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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: CROSSLINE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 304371523
VISIT DATE: 10/21/2021
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The following were inspected in the indoor activity space:
· Classroom are adequately equipped with age and size appropriate furniture and equipment
· 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 shall be stored in individual cubbies when not in use and Cribs for younger infants and roll up urban mats for older infants /toddlers shall be used.
· The changing table is within arm’s reach of a sink/ the changing table is padded with raised sides
· All bedding linens are provided by the parents.
· There is a designated napping area surrounded by a 4 ft wall with sufficient infant napping equipment's
· The infant indoor is physically separate from the preschool component
Facility has designated labels for Mother's Milk and Formula which are provided to the parents before the bottles are given to the teacher.

Center policy is that formula/ baby food/ Diapers/ pull ups/ lotions / wipes/ crib linens/ personal utensils/ bowls are to be provided by the parents, every infant shall have their own bin to store personal items.
LPA discussed the posting requirements including, but limited to, the following:
· Facility License in public area (101160)
· Emergency Disaster Plan (LIC 610) / Earthquake Preparedness Check List (LIC 9148)
· Parents’ Rights Poster (PUB 393)
· Personal Rights (LIC 613A)
· Menus / Activity Schedule
· Notice of Site Visit (LIC 9213) and Type A deficiencies / Plan of Corrections of Type A deficiencies
· Granted Waivers (available for review)
· Child Car Seat Law (PUB 269)
· Sudden Infant Death Syndrome Poster
· Shaken Baby Syndrome Poster (page-2)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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: CROSSLINE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 304371523
VISIT DATE: 10/21/2021
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Indoor activity space : Infant rooms and Toddler room

Room Identification Length Width
Area
Emcumbered
Space
Room # 1 (Infants)
25.25
12.5
315.63
106.05
209.58
Room # 2 Infants
24.25
23.5
569.88
173.55
396.33
Room #3 (Toddler)
24.33
18.83
458.13
8.64
449.49
Total Indoor space : 1055’40 Sq Feet divided by 35 = 30’15 ( 30 Infants)

3 sinks ( One sink in each classroom ) x 15= 45


6 Potty chairs in two infant rooms x 5= 30 Infants
3 Potty Chairs in one toddler room. x 5 = 15 Toddlers

Infant yard : Outdoor activity area

The following were inspected in the outdoor activity space;
· Playground is fully enclosed by an appropriate fencing
· Outdoor activity space is supplied with age and size appropriate equipment's
· An adequate amount of cushioning material consisting of regular turf grass
· Adequate shade is provided by canopy
One Infant yard is accessed through the infant room #1, while the Infant / Toddler yard shall be accessed through the passage area. Facility shall use strollers for Infants during transition to yard and Toddlers shall walk with the ongoing supervision.

Area Identification LengthWidth
Area
Encumbered
Space
Infant yard outside room # 1
24.5
12.83
314.34
314.34
Infant /Toddler yard
42.17
20.58
867.86
867.86

Total outdoor space: 1182’19 divided by 75 = 15’76 (16 infants) (Page-3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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: CROSSLINE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 304371523
VISIT DATE: 10/21/2021
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LPA discussed with the applicant/facility representative that all employees must have criminal record clearances associated to the facility prior to their presence in the facility, staff to child ratio requirements, direct visual supervision requirements, emergency/disaster drills, children records, mandated reporter training, and staff immunization requirements against measles, pertussis, and influenza. Applicant/facility representative was advised the infant crib area must be supervised at all times. No infant should be left unattended in the crib area, bedding must be stored individually and may not touch another children's bedding.

Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to down load forms, Title 22 regulations, and training's on-line at www.ccld.ca.gov. The applicant/facility representative was also informed to visit the website for Quarterly Updates.

The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. or at www.ccld.ca.gov

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The applicant/facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the applicant/facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

(Page-4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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: CROSSLINE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 304371523
VISIT DATE: 10/21/2021
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NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a T-shirt and not be too hot or too cold.

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian. Applicant has complete access to the new Guardian system.

A copy of PIN 20-24 was also provided to the applicant.

Based on today’s measurements, this center has sufficient Indoor activity space to support the capacity of 16 infants in Room # 1 and 2 and 12 Toddlers in Room # 3 as requested. (28 total capacity) . Facility will request a Waiver for sharing the outdoor space between Infants and Toddlers with a staggered schedule. Fire clearance has been granted by Orange County Fire office approving the requested capacity.
A license will be issued for the capacity of 16 Infants ( 6 weeks - 24 months) in Room # 1 and 2, Toddlers (18 months to 36 months in Room # 3) after a final review. Applicant shall be notified if additional information is needed. (Total Capacity: 28)

The facility was in compliance with Title 22 requirements at the time of the inspection. (Page-5)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: CROSSLINE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 304371523
VISIT DATE: 10/21/2021
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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

Medication will be stored in the Director's office in a locked cabinet and shall be administered by the teacher or the Facility in charge, emergency First Aid kits are stored in the classrooms and in the in assigned cabinets. Medication administration forms were reviewed.
Isolation area is the Director’s office and the sick child shall use the restroom located next to the lobby area there is an additional mat and linens for the sick child.

Applicant was also advised, once licensed, the Notice of Site Visit must be posted for 30 days and if A violations are cited then the Licensing Report (LIC809 or 9099) must be posted by the Notice of Site Visit for a period of 30 days or $100 civil penalties will be assessed, and the report shall posted and copies provided to the parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

The report was reviewed and discussed with Facility Administrator Ms. Stark, Michele and Church Representative Ms. Carrasco, Marci

An exit interview was completed.

Appeal Rights were discussed. The applicant was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days (End of report)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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