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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376301121
Report Date: 07/27/2026
Date Signed: 07/27/2026 02:41:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2026 and conducted by Evaluator Kelly Gerth
PUBLIC
COMPLAINT CONTROL NUMBER: 10-CC-20260604171944
FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
376301121
ADMINISTRATOR:BEEBE, DARLENEFACILITY TYPE:
860
ADDRESS:643 WEST 13TH AVENUETELEPHONE:
(760) 747-3029
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:135CENSUS: 39DATE:
07/27/2026
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Director Ann GrossmanTIME COMPLETED:
03:01 PM
ALLEGATION(S):
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Facility did not prevent staff from operating out of ratio.
INVESTIGATION FINDINGS:
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 On the above date and time, Licensing Program Analyst (LPA) Kelly Gerth arrived at the facility to deliver the findings from a complaint received by Community Care Licensing (CCL) on June 04, 2026. LPA met with LPA met with Grace Lutheran Preschool (CCC) Director Ann Grossman and provided the purpose of the visit. LPA toured the facility and took census. It was alleged that Facility did not prevent staff from operating out of ratio.
On 06/09/2026 LPA Gerth opened the investigation at the CCC. During the visit, LPA toured the facility, conducted staff interviews, collected evidence and made observations. On 06/05/26, 06/09/26 and 06/26/26 LPA attempted to conduct an interview with the reporting party (RP) but was unsuccessful in communication attempts. On 06/26/26, LPA Gerth made a subsequent visit to the CCC to conduct further interviews with staff, children and administration as well as collected evidence pertinent to the investigation and conducted additional observations.
Regarding the allegation that the facility did not prevent staff from operating out of ratio. On 06/09/26 and 06/26/26, LPA Gerth conducted interviews with staff and administrators and reviewed relevant licensing records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
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 6
Control Number 10-CC-20260604171944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 376301121
VISIT DATE: 07/27/2026
NARRATIVE
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 Information obtained during the investigation indicated that the CCC is currently undergoing a transition in management.
. During an internal review of licensing documents, the CCC determined that, although management believed the facility was approved to operate a toddler component, the current license authorizes care only for infants (0–24 months) and preschool-aged children (2–5 years).
A review of Community Care Licensing records further reflected that, during the facility's application process for an infant license, the CCC initially expressed interest in obtaining a toddler component. However, during the case management visit conducted by CCL on 09/15/25, the facility submitted an updated application removing the toddler component from the request. Although the classroom names remained unchanged, including the designation "Infant/Toddler Room," the facility was not licensed to operate a toddler component.
Interviews and record review indicated that, during the facility's recent internal restructuring, the CCC temporarily staffed the Infant/Toddler Room using a 1:6 staff-to-child ratio consistent with a toddler component, rather than the licensed infant ratio of 1:4. Upon identifying the discrepancy, the Director and Administrator immediately adjusted staffing to comply with the facility's licensed capacity and ratio requirements. At the time of the investigation, the classroom was operating within the licensed 1:4 staff-to-child ratio. Based on LPA’s observation, interviews and documents gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

An exit interview was conducted, and this report was reviewed with Director Ann Grossman. Appeal rights were discussed and provided during the exit interview. A notice of site visit was given and licensee understands this must remain posted for 30 days.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2026 and conducted by Evaluator Kelly Gerth
PUBLIC
COMPLAINT CONTROL NUMBER: 10-CC-20260604171944

FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
376301121
ADMINISTRATOR:BEEBE, DARLENEFACILITY TYPE:
860
ADDRESS:643 WEST 13TH AVENUETELEPHONE:
(760) 747-3029
CITY:ESCONDIDOSTATE:CAZIP CODE:
92025
CAPACITY:135CENSUS: 39DATE:
07/27/2026
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Director Ann GrossmanTIME COMPLETED:
03:01 PM
ALLEGATION(S):
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Staff yells at children in care
Staff are not adequately supervising children in care
Staff engaged in verbal altercations in the presence of day-care children.
Facility is allowing unqualified staff to provide care and supervision to children in care.
Staff are not allowing children to use the restroom as needed.
Staff are not reporting incidents to authorized representatives for children in care.
INVESTIGATION FINDINGS:
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 On the above date and time, Licensing Program Analyst (LPA) Kelly Gerth arrived at the facility to deliver the findings from a complaint received by Community Care Licensing (CCL) on June 04, 2026. LPA met with Grace Lutheran Preschool (CCC) Director Ann Grossman and provided the purpose of the visit. LPA toured the facility and took census. It was alleged that Staff yells at children in care, Staff are not adequately supervising children in care, Staff engaged in verbal altercations in the presence of day-care children, Facility is allowing unqualified staff to provide care and supervision to children in care, Staff are not allowing children to use the restroom as needed, and Staff are not reporting incidents to authorized representatives for children in care.
On 06/09/2026 LPA Gerth opened the investigation at the CCC. During the visit, LPA toured the facility, conducted staff interviews, collected evidence and made observations. On 06/05/26, 06/09/26 and 06/26/26 LPA attempted to conduct an interview with the reporting party (RP) but was unsuccessful in communication attempts. On 06/26/26, LPA Gerth made a subsequent visit to the CCC to conduct further interviews with staff, children and administration as well as collected evidence pertinent to the investigation and conducted additional observations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 10-CC-20260604171944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 376301121
VISIT DATE: 07/27/2026
NARRATIVE
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 Regarding the allegation that staff yell at children in care: During the course of the investigation, the LPA interviewed 10 staff members and 3 children. The LPA was unable to make contact with the reporting party for an interview. Interviews conducted with staff and children were consistent in that no one reported observing staff yell at children in care or expressed concerns regarding staff behavior toward children. Although the individuals interviewed acknowledged that some staff naturally speak at varying volume levels, they indicated that staff do not yell at children. Several staff explained that during scheduled outdoor activities, teachers may raise their voices to ensure children are able to hear directions and maintain safety; however, they stated this is done in an appropriate manner and tone and is not considered yelling. LPA did not find a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.
Regarding the allegation that staff are not adequately supervising children in care. On 06/09/26 and 06/26/26, LPA Gerth conducted interviews with staff members assigned to classrooms serving all age groups. Additional interviews were conducted with administrative and support staff. Information obtained through interviews indicated that the CCC identifies active supervision as a priority and that no incidents resulting from inadequate supervision were reported by the individuals interviewed. Those interviewed further stated that the CCC has not been made aware of any concerns regarding staff supervision of children in care. A review of CCL records found no reported unusual incidents involving inadequate supervision, and the CCC denied having any unreported incidents related to supervision. Therefore, the allegation is deemed UNSUBSTANTIATED.
Regarding the allegation that staff engaged in verbal altercations in the presence of day-care children. During interviews conducted on 06/09/26 and 06/26/26, staff consistently reported that while differences of opinion may occasionally arise in the workplace, they have not observed concerns regarding professional conduct. The individuals interviewed acknowledged that staff have, at times, engaged in discussions where differing viewpoints were expressed; however, they stated that these interactions remained professional, did not involve inappropriate communication, and did not escalate into verbal altercations, whether in the presence of children or adults. Therefore, at this time there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegation is UNSUBSTANTIATED.
Regarding the allegation that the facility is allowing unqualified staff to provide care and supervision to children in care. Interviews conducted on 06/09/26 and 06/26/26 indicated that the CCC has utilized temporary/substitute teachers and administrative staff to provide classroom support as needed. However, the individuals interviewed consistently reported that staff providing temporary classroom coverage were assigned
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 10-CC-20260604171944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 376301121
VISIT DATE: 07/27/2026
NARRATIVE
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duties consistent with their qualifications and were not asked to perform responsibilities for which they were unqualified. A review of personnel records further reflected that staff employed by the CCC met the qualifications for their assigned positions. Additionally, a review of the facility's annual inspection history did not identify any deficiencies related to staff qualifications. Therefore, based on interviews conducted, records reviewed, and evidence obtained during the investigation, the allegation is determined to be UNSUBSTANTIATED.
Regarding the allegation that staff are not allowing children to use the restroom as needed. During the investigation, LPA Gerth conducted interviews, gathered relevant evidence, and made observations at the facility. On 06/26/26, LPA Gerth observed classrooms throughout the CCC transitioning children to and from the restrooms on a regular basis. The LPA also observed that when classroom staff requested assistance to facilitate children's restroom breaks, support staff responded promptly and appropriate classroom coverage was consistently provided. Interviews conducted with children further indicated that when they requested to use the restroom, staff responded within a reasonable timeframe and facilitated access to the restroom as needed. Therefore, LPA did not find a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.
Regarding the allegation: Staff are not reporting incidents to authorized representatives for children in care. During the investigation, LPA conducted confidential interviews with staff from all classroom age groups. Interviews corroborated that staff following a specific internal incident reporting process. Recent ouch/incident reports from the time frame just prior to the complaint allegations made, were taken into evidence and reflect that the authorized representatives of children had been notified in writing, in a timely manner as well and confirmed receipt of notification. The CCC does not have knowledge of any parent concern of unreported incident/ouch reports and staff also deny awareness of any such concerns. Therefore, based on interviews conducted and evidence obtained, LPA did not find a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.
An exit interview was conducted, and this report was reviewed with Director Ann Grossman. Appeal rights were discussed and provided during the exit interview. A notice of site visit was given and licensee understands this must remain posted for 30 days.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 10-CC-20260604171944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 376301121
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2026
Section Cited
CCR
101416.5(b)
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101416.5 Staff-Infant Ratio (b) There shall be a ratio of one teacher for every four infants in attendance. This requirement was not met as evidenced by;

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CCC Director immediately adjusted staffing and LPA confirmed the CCC has been operating at the 1:4 ratio for which they are licensed. Plan of Correction met at time of visit.
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Based on interview, observation and evidence gathered the CCC did not comply with the ratio as they had temporarily operated at a 1:6 ratio for older infants which posed a potential health, safety or personal rights risk to children 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.
SUPERVISOR'S NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelly Gerth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6