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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418346
Report Date: 06/10/2021
Date Signed: 06/10/2021 10:29:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:BETHLEHEM LUTHERAN SCHOOLFACILITY NUMBER:
197418346
ADMINISTRATOR:FERRARA, TONIFACILITY TYPE:
850
ADDRESS:27265 LUTHER DRIVETELEPHONE:
(661) 251-6027
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY:98CENSUS: 17DATE:
06/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Toni Ferrara, DirectorTIME COMPLETED:
10:45 AM
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On 06/10/2021 Licensing Program Analyst (LPA) Monique Ayala conducted a Case Management -Deficiencies inspection for the purpose of determining whether Staff #1 was present in the facility. During today's inspection, LPA was greeted by director, and granted entry. LPA did not observe Staff #1. Upon arrival, LPAs observed 17 children and 4 staff members.

During today's inspection, director stated that Staff #1 is not present at the facility. Director understand that Staff #1 can not be employed until fingerprint cleared.

No citations will be issued today. An Exit Interview was conducted, a copy of this Report, Appeal rights and a Notice of Site visit was provided to the director.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 369-2168
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: (661) 202-3365
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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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