ST. PETER'S LUTHERAN SCHOOL

Type A citation from complaint investigation - immediate risk

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 26 27 28 29 30 31 32Based on the interview with the director who described the incident, there is a preponderance of evidence to support the above allegation, where a preschool child was left without staff supervision on the playground. THEREFORE THE ABOVE ALLEGATION IS SUBSTANTIATED. A Title 22 Type A deficiency was cited today on the subsequent page 9099-D. As a result of the deficiency, Director Stringer understands that LIC 9224 must be signed by all current authorized representatives and potential authorized representatives for up to one year. The LIC 9224 must be kept in each child's file for the Department's review. An exit interview was conducted, and the report was reviewed with Director Stringer. LPA provided Ms. Stringer with Licensee Appeal Rights. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023 FACILITY NAME: ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER: 340320556 DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 07/18/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 07/19/2023 Section Cited CCR 101229(a)(1)1 2 3 4 5 6 7(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. 1 2 3 4 5 6 7Director stated there were staff meetings about supervision and transitioning children. Director will send LPA documentation of meeting minutes. 8 9 10 11 12 13 14This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

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 26 27 28 29 30 31 32Based on the interview with the director who described the incident, there is a preponderance of evidence to support the above allegation, where a preschool child was left without staff supervision on the playground. THEREFORE THE ABOVE ALLEGATION IS SUBSTANTIATED. A Title 22 Type A deficiency was cited today on the subsequent page 9099-D. As a result of the deficiency, Director Stringer understands that LIC 9224 must be signed by all current authorized representatives and potential authorized representatives for up to one year. The LIC 9224 must be kept in each child's file for the Department's review. An exit interview was conducted, and the report was reviewed with Director Stringer. LPA provided Ms. Stringer with Licensee Appeal Rights. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023 FACILITY NAME: ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER: 340320556 DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 07/18/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 07/19/2023 Section Cited CCR 101229(a)(1)1 2 3 4 5 6 7(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. 1 2 3 4 5 6 7Director stated there were staff meetings about supervision and transitioning children. Director will send LPA documentation of meeting minutes. 8 9 10 11 12 13 14This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

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 26 27 28 29 30 31 32Based on the interview with the director who described the incident, there is a preponderance of evidence to support the above allegation, where a preschool child was left without staff supervision on the playground. THEREFORE THE ABOVE ALLEGATION IS SUBSTANTIATED. A Title 22 Type A deficiency was cited today on the subsequent page 9099-D. As a result of the deficiency, Director Stringer understands that LIC 9224 must be signed by all current authorized representatives and potential authorized representatives for up to one year. The LIC 9224 must be kept in each child's file for the Department's review. An exit interview was conducted, and the report was reviewed with Director Stringer. LPA provided Ms. Stringer with Licensee Appeal Rights. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023 FACILITY NAME: ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER: 340320556 DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 07/18/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 07/19/2023 Section Cited CCR 101229(a)(1)1 2 3 4 5 6 7(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. 1 2 3 4 5 6 7Director stated there were staff meetings about supervision and transitioning children. Director will send LPA documentation of meeting minutes. 8 9 10 11 12 13 14This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

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 26 27 28 29 30 31 32Based on the interview with the director who described the incident, there is a preponderance of evidence to support the above allegation, where a preschool child was left without staff supervision on the playground. THEREFORE THE ABOVE ALLEGATION IS SUBSTANTIATED. A Title 22 Type A deficiency was cited today on the subsequent page 9099-D. As a result of the deficiency, Director Stringer understands that LIC 9224 must be signed by all current authorized representatives and potential authorized representatives for up to one year. The LIC 9224 must be kept in each child's file for the Department's review. An exit interview was conducted, and the report was reviewed with Director Stringer. LPA provided Ms. Stringer with Licensee Appeal Rights. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023 FACILITY NAME: ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER: 340320556 DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 07/18/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 07/19/2023 Section Cited CCR 101229(a)(1)1 2 3 4 5 6 7(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. 1 2 3 4 5 6 7Director stated there were staff meetings about supervision and transitioning children. Director will send LPA documentation of meeting minutes. 8 9 10 11 12 13 14This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

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 26 27 28 29 30 31 32Based on the interview with the director who described the incident, there is a preponderance of evidence to support the above allegation, where a preschool child was left without staff supervision on the playground. THEREFORE THE ABOVE ALLEGATION IS SUBSTANTIATED. A Title 22 Type A deficiency was cited today on the subsequent page 9099-D. As a result of the deficiency, Director Stringer understands that LIC 9224 must be signed by all current authorized representatives and potential authorized representatives for up to one year. The LIC 9224 must be kept in each child's file for the Department's review. An exit interview was conducted, and the report was reviewed with Director Stringer. LPA provided Ms. Stringer with Licensee Appeal Rights. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023 FACILITY NAME: ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER: 340320556 DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 07/18/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 07/19/2023 Section Cited CCR 101229(a)(1)1 2 3 4 5 6 7(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. 1 2 3 4 5 6 7Director stated there were staff meetings about supervision and transitioning children. Director will send LPA documentation of meeting minutes. 8 9 10 11 12 13 14This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

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 25 26 27 28 29 30 31 32Based on the interview with the director who described the incident, there is a preponderance of evidence to support the above allegation, where a preschool child was left without staff supervision on the playground. THEREFORE THE ABOVE ALLEGATION IS SUBSTANTIATED. A Title 22 Type A deficiency was cited today on the subsequent page 9099-D. As a result of the deficiency, Director Stringer understands that LIC 9224 must be signed by all current authorized representatives and potential authorized representatives for up to one year. The LIC 9224 must be kept in each child's file for the Department's review. An exit interview was conducted, and the report was reviewed with Director Stringer. LPA provided Ms. Stringer with Licensee Appeal Rights. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. SUPERVISORS NAME: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023 FACILITY NAME: ST. PETER'S LUTHERAN SCHOOLFACILITY NUMBER: 340320556 DEFICIENCY INFORMATION FOR THIS PAGE:VISIT DATE: 07/18/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type A 07/19/2023 Section Cited CCR 101229(a)(1)1 2 3 4 5 6 7(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. 1 2 3 4 5 6 7Director stated there were staff meetings about supervision and transitioning children. Director will send LPA documentation of meeting minutes. 8 9 10 11 12 13 14This requirement was not met as evidenced by LPA learned from Director interview that a child was left on the playground without staff supervision.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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: Bettina Engelman LICENSING EVALUATOR NAME: Jennie Tedlos LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023