300602027-5-1-2020-06-CC-JMHN-BLJM68-20200206081930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 02/05/2020
Date Signed: 05/01/2020 02:46:41 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 LANE		TELEPHONE:	(714) 639-1946
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	101	CENSUS: 47	DATE:	02/05/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kathy Vickers		TIME COMPLETED:	11:30 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	This is Amend report A case management inspection was conducted today by Licensing Program Analyst (LPA) Jungmi (Jamie) Han conducted an inspection at the facility for the purpose of adding rooms without capacity increase. The facility is currently using 6 rooms (room A2, A3, A4, A5, A6, B4, B5) and adding 3 more rooms for preschool children’s special programs: B6, Sanctuary, and Gym/Multipurpose room. Preschool children’s capacity remains same as current 101. Fire clearance from the Orange Fire Department has been received and approved for requested capacity of 101 children and room A2, A3, A4, A5, A6, B4, B5, B6, Sanctuary, Gym with special conditions as below. Special conditions: Previous licenses indicate rooms A2, A3, A4, A5, A6, B4, B5 were approved for preschool use. Room B6 is authorized for use as a multipurpose room under following conditions: not for daily use, occupancy load not to exceed 30 students. Sanctuary and Gym are authorized for their intended use as such changes to above capacity shall require review by this department. LPA met with director, Kathy Vickers. LPA Han toured the facility inside and outside. Census was taken. There was a total of 47 preschool children with 7 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. LPA Han toured the entire facility indoors & outdoors and the following measurements were taken: Indoor: Room A2: 283.50 div. 35 = 8.1 Room A3: 497.83 div. 35 = 14.22 Room A4: 358.09 div. 35 = 10.23 Page 1 of 3

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (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)

Page: 1 of 3

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: 02/05/2020

NARRATIVE

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Page 2 **This is an Amend report **
Room A5: 358.09 div. 35 = 10.23
Room A6: 358.09 div. 35 = 10.23
Room B4: 840.50 div. 35 = 24.01
Room B5: 840.50 div. 35 = 24.01
Room B6: 840.50 div. 35 = 24.01

Total indoor space= 4377.07 S.F.
Total indoor space ONLY for preschool children (without B4 and B6) = 2696.07 S.F div. 35 = 77 children

Total children toilets and sinks:

Restroom in A building: Toilet 3, Sink 4, Urinal 1
Toilets/Urinal: 4 x 15 - 60 children
Sink : 4 x 15 = 60 children

Outdoor:
7927.24 square feet/ 75= 105 children

Based on today’s measurement, the Max. capacity for preschool children is 60 without restroom waiver.

The director stated currently room B4 is using by 1^st grade children and may use room B4 for preschool children in the future. Director also stated room B6, Sanctuary, and Gym will be used by preschool children for special program and not exceed 30 children in room B6.

Director submitted

Daily/weekly/monthly schedule to use room B6, Sanctuary, and Gym by preschool children
A statement to use room B4 for 1st grade children
A statement to use restrooms between library and room B2 with rotating schedule with elementary children and visual supervision by staff.

Page 2 of 3

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (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

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 02/05/2020

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Page 3 *This is an Amend report **
Director was informed to contact licensing office by submitting facility sketch and statement when the facility changes rooms.

Director was informed to contact licensing office to add room B4 and B6 when it is ready to use only for preschool children.

Director was reminded about teacher-child ratio requirements, direct visual supervision requirements, emergency/disaster drills, posting requirements, children records, mandated child abuse and injury/ death reporting, mandated reporter training, immunization requirements against measles, pertussis, and influenza and fingerprint clearance requirements.

Licensee will submit proofs via email of the corrections to be completed to LPA within 30 days of today’s date. LPA informed applicant that a final review of the file will be done before the license is issued. The licensee will be notified if any corrections or additions still need to be completed.

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 1/16) 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: 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

LIC809 (FAS) - (06/04)

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