CONCORDIA LUTHERAN KING'S CLUB

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 10/15/2025, at 1:15pm, Licensing Program Analyst (LPA) Jonnisha Culbert conducted an unannounced required 3yr. inspection at the facility noted above and met with licensee Elizabeth Medina. LPA stated the purpose of today’s visit and provided licensee with an Entrance Checklist for Child Care Centers (LIC 125). Licensee guided LPA on a tour of the facility. This is an after-school program located on the premises of Concordia Lutheran Church. Per licensee, the program operates Monday through Friday before school from 7am to 6:30. Present at the time of today’s inspection were licensee and 4 staff. Children were not present at the facility during the time of the inspection. report is a contains inf:30pmormation collected on 10/03/2025 and 10/15/2025. The following documents are posted in a prominent, publicly accessible area: Facility License, Menu, Child Passenger Restraint System Poster (PUB 269), Notification of Parents' Rights (PUB 393), Emergency Disaster Plan (LIC 610), Personal Rights (LIC 613A), Daily Activity Schedule, and Earthquake Preparedness (LIC 9148). Furniture and equipment were inspected for age appropriateness and good repair. LPA evaluated each classroom and observed that chairs, tables, and learning tools were age-appropriate. Telephone service, heating, lighting, and ventilation were evaluated to ensure that a comfortable environment can be provided. Sinks and toilets were inspected for availability and good repair. General sanitation was observed. Per licensee, when children become ill, they wait in the main office or director’s office (isolation area) until picked up by parents. NAME OF LICENSING PROGRAM MANAGER: Warren Birks NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025 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 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 l

Type B citation - potential risk if not corrected

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 10/15/2025, at 1:15pm, Licensing Program Analyst (LPA) Jonnisha Culbert conducted an unannounced required 3yr. inspection at the facility noted above and met with licensee Elizabeth Medina. LPA stated the purpose of today’s visit and provided licensee with an Entrance Checklist for Child Care Centers (LIC 125). Licensee guided LPA on a tour of the facility. This is an after-school program located on the premises of Concordia Lutheran Church. Per licensee, the program operates Monday through Friday before school from 7am to 6:30. Present at the time of today’s inspection were licensee and 4 staff. Children were not present at the facility during the time of the inspection. report is a contains inf:30pmormation collected on 10/03/2025 and 10/15/2025. The following documents are posted in a prominent, publicly accessible area: Facility License, Menu, Child Passenger Restraint System Poster (PUB 269), Notification of Parents' Rights (PUB 393), Emergency Disaster Plan (LIC 610), Personal Rights (LIC 613A), Daily Activity Schedule, and Earthquake Preparedness (LIC 9148). Furniture and equipment were inspected for age appropriateness and good repair. LPA evaluated each classroom and observed that chairs, tables, and learning tools were age-appropriate. Telephone service, heating, lighting, and ventilation were evaluated to ensure that a comfortable environment can be provided. Sinks and toilets were inspected for availability and good repair. General sanitation was observed. Per licensee, when children become ill, they wait in the main office or director’s office (isolation area) until picked up by parents. NAME OF LICENSING PROGRAM MANAGER: Warren Birks NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025 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 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 l