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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 09/22/2020
Date Signed: 09/22/2020 01:50:29 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: 39DATE:
09/22/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Ms Vickers Kathy TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ketki Desai conducted an unannounced Case Management Licensee initiated inspection for adding a new sink and one toilet to the current Preschool license. The capacity for Preschool shall decrease to 75 preschoolers.

LPA met with Facility Administrator Ms. Vickers Kathy, who gave a tour of the Preschool classrooms and the new toilet and sink located just outside the preschool play yard.

The new sink and bathroom would be accessible to preschool classroom children only. There are additional sinks and bathrooms in the facility and now with the addition of new sink and toilet the count is as follows:

A building has (/2 stalls and 2 sinks in girls’ bathroom) (1 stall and 1 urinal with 2 sinks inside the boy’s restroom) 1 communal sink for preschoolers outside the restroom area and classroom B5 has one sink inside.


On todays inspection one sink and one stall is being added to the preschool license.
Toilets/Urinal: 5 x 15 - 75 children
Sinks: 7 x 15 = 105 children

The preschool rooms were observed to have age and size appropriate, furniture, activities, toys and educational items.

Based on today's inspection facility has enough space for the requested capacity of 75 Preschoolers (2 years – 6 years). Monday to Friday 7.00 am to 6.00 PM.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020
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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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: 09/22/2020
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Administrator Ms. Vickers Kathy is current on the required CPR training (8/22) and facility has completed the new Water testing requirement

License shall be granted after the final approval by the management.

Report was read to the Facility Administrator and appeal rights were provided.

Notice of site visit posted.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020
LIC809 (FAS) - (06/04)
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