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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501048
Report Date: 10/03/2019
Date Signed: 10/03/2019 03:11:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CONCORDIA LUTHERAN PRE-SCHOOLFACILITY NUMBER:
191501048
ADMINISTRATOR:SUSAN JENNINGSFACILITY TYPE:
850
ADDRESS:13633 183RD ST.TELEPHONE:
(562) 926-7416
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:60CENSUS: 23DATE:
10/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Susan Jennings, DirectorTIME COMPLETED:
03:30 PM
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An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) A. Lucero to address an Unusual Incident Report that was received in the licensing office on 10/01/2019. LPA met with Director Susan Jennings who guided LPA on a tour of facility of both indoors and outdoors.

It was reported that on 09/30/2019 in which an possible incident occurred involving two children at the school. Based on all information obtained on this date, and interviews conducted with staff, follow-up may be necessary regarding the incident.

There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.

Exit interview, copy of report was given. Appeal rights were issued and discussed.

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Armando J LuceroTELEPHONE: (323) 981-3435
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2019
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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