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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493794
Report Date: 11/14/2019
Date Signed: 11/18/2019 10:19:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:VISION PRESCHOOL- SCHOOL AGEFACILITY NUMBER:
197493794
ADMINISTRATOR:KIM, SOOK KIFACILITY TYPE:
840
ADDRESS:20440 LASSEN STREETTELEPHONE:
(818) 895-7643
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:25CENSUS: 22DATE:
11/14/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sook Ki KimTIME COMPLETED:
04:30 PM
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Margarit Sislyan, Licensing Program Analyst (LPA) arrived at the facility to deliver the reports from the visit of 11/13/19.

Due to technical problem, LPA was not able to print the reports on 11/13/19.

Exit interview

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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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