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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 05/01/2020
Date Signed: 05/01/2020 12:58:54 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 PRESCHOOLFACILITY NUMBER:
300602027
ADMINISTRATOR:VICKERS, KATHYFACILITY TYPE:
850
ADDRESS:6411 EAST FRANK LANETELEPHONE:
(714) 639-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:101CENSUS: 0DATE:
05/01/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kathy VickersTIME COMPLETED:
01:00 PM
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Tele-Inspection

A Tele-inspection was conducted on this date by Licensing Program Analyst (LPA) Jungmi Han for the purpose of amending 2/5/2020 report. Due to COVID-19, the facility is currently closed. A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

There were no Title 22 deficiencies cited during today's inspection.

An exit interview was completed with director. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 309-7211
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2020
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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