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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 240405513
Report Date: 02/05/2020
Date Signed: 02/05/2020 12:29:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:ST. PAULS' EVANGELICAL LUTHERAN CHURCH OF MERCEDFACILITY NUMBER:
240405513
ADMINISTRATOR:FAULKNER, ANGELIQUEFACILITY TYPE:
850
ADDRESS:2916 N. MCKEE ROADTELEPHONE:
(209) 383-5672
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:55CENSUS: 41DATE:
02/05/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angelique Faulkner - DirectorTIME COMPLETED:
12:45 PM
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On 2/5/2020 at 11:45am, Licensing Program Analyst (LPA), Joseph Pacheco arrived at the facility to conduct an unannounced Case Management - Licensee Initiated inspection. The purpose of the inspection was to inspect the Parish Hall which is used by preschool students during day care hours. This facility has submitted a written proposal for the Parish Hall to be shared during lunch time by pre-school students and students from Kindergarten through Sixth grade that attend St. Paul Elementary School. Lunchtime is scheduled between 11:40am – 12:25pm Monday through Friday. The elementary school students will not be using the Parish Hall at any other time during day care hours. Elementary school students will have their own separate entrance and exit into and out of the Parish Hall. The pre-school students will be using the east side of the Parish Hall and the elementary school students will be using the west side of the Parish Hall. The pre-school students will be separated from the elementary school students by a barrier located in the middle of the Parish Hall. Elementary school students will be supervised by their own staff. LPA and Director conducted a tour of the Parish Hall. LPA observed that the following conditions have been met:

· Facility will have separate trash cans during lunch time for elementary school students and for preschool students.

· Licensee is responsible for providing adequate supervision in the Parish Hall for the preschool children and maintaining teacher to child ratios at all times.

· Parish Hall will have separate bathrooms for preschool students and elementary school students.

The proposed set up has been approved by the LPA effective 2/5/2020. Director understands that any proposed change to this set up must be submitted to Community Care Licensing in advance.

Per California Code of Regulations, Title 22, Division 12, Chapter 1, no deficiencies cited during today's visit.

Exit interview conducted with Director. LIC 9213 Notice of Site Visit to be posted for 30 days.

SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2020
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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