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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407546
Report Date: 06/06/2019
Date Signed: 06/06/2019 12:05:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:NOAH'S ARK PRESCHOOL-QUARTZ HILL FOURSQUARE CHURCHFACILITY NUMBER:
197407546
ADMINISTRATOR:THOMPSON, MICHELLEFACILITY TYPE:
850
ADDRESS:6015 WEST AVEUNE J-8TELEPHONE:
(661) 943-4440
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:60CENSUS: DATE:
06/06/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michelle Thompson, TIME COMPLETED:
12:13 PM
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Licensing Program Analysts (LPA) Lady King-Lewis met with Center Director Michelle Thompson, today for the purpose of conducting an unannounced Case Management inspection to notify the facility that a conditional criminal record exemption for staff 1.

This exemption is approved with the following conditions:

1. Staff 1 may not transport clients

2. The individual does not violate any licensing laws or regulations.

3. The individual does not engage in conduct that indicates that he/she may pose a risk to the health and safety of any individual who is or may be a client.

4. The individual does not fail to disclose a conviction even if it occurred before the exemption was granted.

5. The individual is not convicted of a subsequent crime.

The Center is aware if the individual or the center do not wish to accept these conditions, the conditional exemption can be decline. Center is not declining the exemption approval.

Exit interview was conducted, appeal rights and a copies of Conditional Exemption Approval and inspection report were provided along with the Notice of Site Visit on this date.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 789-6944
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2019
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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