300602027-11-23-2019-06-CC-JMHN-BJ7TH7-20191123134415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 11/22/2019
Date Signed: 11/23/2019 01:44:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	SALEM LUTHERAN PRESCHOOL		FACILITY NUMBER:	300602027
ADMINISTRATOR:	VICKERS, KATHY		FACILITY TYPE:	850
ADDRESS:	6411 EAST FRANK STREET		TELEPHONE:	(714) 639-1946
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	101	CENSUS: 7	DATE:	11/22/2019
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Kathy Vickers		TIME COMPLETED:	09:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	The purpose of this visit was to conduct a case management visit of this facility to follow up 11/19/2019 inspection. Licensing Program Analyst (LPA) Jungmi Han met with director, Kathy Vickers and school principal, Corissa Sheets. Census was taken. There was a total of 7 preschool children with 2 preschool staff observed. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The child care site is currently licensed to use rooms A3, A4, A5, A6, B4, and B5. The facility is currently using rooms A2, A3, A4, A5, A6, and B5 rooms for child care. The facility is licensed to use B4 for preschool child care but using it for school age children in 2019. Director submit the statement to LPA Han for B4 classroom. On 11/19/2019, LPA Han conducted annual inspection and found out the facility is using A2 (previously called A9) for preschool children. Room A2 was not on the fire clearance report for child care that was issued on 9/19/2000. Director stated A2 is used by 2-3 years old preschool children and there are currently 8 children enrolled. LPA Han reviewed files and previous reports but couldn't find information about room A2 that has been approved to use for preschool children. Director stated room A2 has been used 1994-2011, 2015, 2018, 2019. Facility did not use A2 in 2012, 2013, 2014, 2016, 2017. Director was told that A2 is allowed up to 9 children by previous director. Page 1 of 2

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2019

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SALEM LUTHERAN PRESCHOOL	FACILITY NUMBER: 300602027
	VISIT DATE: 11/22/2019

NARRATIVE

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On 11/22/2019, LPA Han received from director
(1) Application (LIC 200A)

To add room A2, B6, Sanctuary, and Multipurpose Room without change capacity
Update facility address
Update children’s age range to “2 through 6”

(2) Facility Sketch (LIC 999)
(3) Annual Fire inspection (valid from 1/1/2019 to 1/31/2020) report for whole school business
(4) Statement that room B4 is currently used as a 1 st grade classroom.

LPA Han discussed issues on this facility with LPM Magana and LPM Hanson.

Exit interview was conducted, and report was reviewed and discussed. Notice of Site Visit was posted during the visit. The facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100 per day. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The facility representative was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.

End of Report

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2019

LIC809 (FAS) - (06/04)

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