ABIDING SAVIOR LUTHERAN CHURCH & SCHOOL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Aiddee Nunez conducted an unannounced case management investigation for the incident which the facility self-reported to licensing office on 5/10/2023. LPA and the facility representative toured the facility inside and outside, and the floor and yard plan were verified. Census was taken in individual classrooms. The overall census observed was 35 preschool children with 6 preschool staff. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. 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. On 5/10/23 director called Community Care Licensing to report an unusual incident which according to the incident report, occurred at the facility on 05/09/23 at 11:55 am. Director stated Child #1 (C1) right-hand pinky got jammed in the right side of the hinge-side of the door while she was standing next to the door that leads to the outside playground and it’s next to the sink, waiting for her turn to wash her hands as a teacher closed the door without knowing that the child’s right hand pinky finger was in the hinge-side of the door. The child’s right hand pinky finger was severely injured causing for the child to receive stiches. On 5/17/2023 LPA Nunez interviewed 3 staff, the Director, (C1) parent, and (C1) about the incident that happened on 5/9/23 in classroom 103. Page 1 of 3 SUPERVISORS NAME: Thuy Ho LICENSING EVALUATOR NAME: Aiddee Nunez LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023 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 4 FACILITY NAME: ABIDING SAVIOR LUTHERAN CHURCH & SCHOOLFACILITY NUMBER: 300600010 VISIT DATE: 07/20/2023 NARRATIVE 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 32On 5/31/2023 LPA interviewed Staff #5 (S5) via telephone. S5 was in the classroom on the day of the incident. According to Staff# 3 (S3) on the day of the incident, S5 was changing Child #2 (C2) diaper when S5 was removing C2 diaper and shoes she noticed sand in C2’s shoes. S3 had just finished changing Child #4 (C4) diaper and offered to dump the sand outside. When S3 opened the door, she saw S4 outside in the playground and asked S4 if she can dump the sand out of the shoe. As S3 was closing the door C1 had her right pinky in the hinge-side of the door that is located next to the sink. S3 did not noticed and closed the door causing C1 to severely injure her right pinky. S5 stated that she was in the classroom a few feet away from the sink that is next to the door where the incident happened but did not witness the incident. On 9/21/22 another similar incident happen of C1 pitching her finger on the outside gate. While in care of the facility. On 5/12/23 the facility has placed a door shield that prevents finger injuries on the inside hinge side of the door that is located next to the sink where the incident happened. However, due to the severity of C1’s injury and from the information available to the LPA it is determined that the facility had violated Title 22 Regulation section 101229(a)(1) related to Supervision. The deficiency is being cited on the attached 809D. This is a Type 'A' violation the Director shall post and provide copies of the report to 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. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file. Page 2 of 3 SUPERVISORS NAME: Thuy Ho LICENSING EVALUATOR NAME: Aiddee Nunez LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023 FACILITY NAME: ABIDING SAVIOR LUTHERAN CHURCH & SCHOOLFACILITY NUMBER: 300600010 VISIT DATE: 07/20/2023 NARRATIVE 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 32An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on

Type A citation - immediate risk to health, safety, or personal rights

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Aiddee Nunez conducted an unannounced case management investigation for the incident which the facility self-reported to licensing office on 5/10/2023. LPA and the facility representative toured the facility inside and outside, and the floor and yard plan were verified. Census was taken in individual classrooms. The overall census observed was 35 preschool children with 6 preschool staff. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. 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. On 5/10/23 director called Community Care Licensing to report an unusual incident which according to the incident report, occurred at the facility on 05/09/23 at 11:55 am. Director stated Child #1 (C1) right-hand pinky got jammed in the right side of the hinge-side of the door while she was standing next to the door that leads to the outside playground and it’s next to the sink, waiting for her turn to wash her hands as a teacher closed the door without knowing that the child’s right hand pinky finger was in the hinge-side of the door. The child’s right hand pinky finger was severely injured causing for the child to receive stiches. On 5/17/2023 LPA Nunez interviewed 3 staff, the Director, (C1) parent, and (C1) about the incident that happened on 5/9/23 in classroom 103. Page 1 of 3 SUPERVISORS NAME: Thuy Ho LICENSING EVALUATOR NAME: Aiddee Nunez LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023 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 4 FACILITY NAME: ABIDING SAVIOR LUTHERAN CHURCH & SCHOOLFACILITY NUMBER: 300600010 VISIT DATE: 07/20/2023 NARRATIVE 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 32On 5/31/2023 LPA interviewed Staff #5 (S5) via telephone. S5 was in the classroom on the day of the incident. According to Staff# 3 (S3) on the day of the incident, S5 was changing Child #2 (C2) diaper when S5 was removing C2 diaper and shoes she noticed sand in C2’s shoes. S3 had just finished changing Child #4 (C4) diaper and offered to dump the sand outside. When S3 opened the door, she saw S4 outside in the playground and asked S4 if she can dump the sand out of the shoe. As S3 was closing the door C1 had her right pinky in the hinge-side of the door that is located next to the sink. S3 did not noticed and closed the door causing C1 to severely injure her right pinky. S5 stated that she was in the classroom a few feet away from the sink that is next to the door where the incident happened but did not witness the incident. On 9/21/22 another similar incident happen of C1 pitching her finger on the outside gate. While in care of the facility. On 5/12/23 the facility has placed a door shield that prevents finger injuries on the inside hinge side of the door that is located next to the sink where the incident happened. However, due to the severity of C1’s injury and from the information available to the LPA it is determined that the facility had violated Title 22 Regulation section 101229(a)(1) related to Supervision. The deficiency is being cited on the attached 809D. This is a Type 'A' violation the Director shall post and provide copies of the report to 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. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file. Page 2 of 3 SUPERVISORS NAME: Thuy Ho LICENSING EVALUATOR NAME: Aiddee Nunez LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023 FACILITY NAME: ABIDING SAVIOR LUTHERAN CHURCH & SCHOOLFACILITY NUMBER: 300600010 VISIT DATE: 07/20/2023 NARRATIVE 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 32An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on