300604497-10-6-2021-06-CC-KDEI-C7JQJL-20211006121256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300604497
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:13:04 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:	CHRIST LUTHERAN PRESCHOOL		FACILITY NUMBER:	300604497
ADMINISTRATOR:	LISA HOLLOWAY		FACILITY TYPE:	850
ADDRESS:	760 VICTORIA STREET		TELEPHONE:	(949) 631-1639
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	122	CENSUS: 98	DATE:	10/06/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Ms. Holloway,Lisa		TIME COMPLETED:	12:30 PM

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	A case management Licensee initiated unannounced inspection was conducted on this date by LPA Ketki Desai. The purpose for today’s inspection was to evaluate the facility for a capacity increase by adding a new classroom # 108 and a new outdoor space as requested by the Licensee. LPA met with director Ms. Holloway Lisa, who gave the tour of the new Preschool classroom # 108 including the formerly licensed classrooms. Facility is currently licensed for 122 Preschool age children, including 12 Toddlers and is now seeking to increase capacity to 134 children ages from 2 to 6 years of age, Monday through Friday, 6.30 AM to 6.30 PM. The program will continue to use the previously assigned rooms (Room # 107,109,110,111,116 for Preschool and Room # 115 for Toddler component. Today Room # 108 is being added today to the Preschool license. This room was used under the Temporary COVID Wavier and now it is being changed to a permanent classroom. All areas identified on the Facility Sketch were inspected. Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Storage for children's belongings and an isolation area with sink, toilet, and mat/cot were inspected. Availability of drinking water was reviewed. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, area safety and sanitation. First Aid supplies were inventoried. Playground is completely enclosed by a fence. Outdoor activity area is supplied with age and size appropriate equipment including a climbing structure. An adequate amount of cushioning material is in place under the equipment. Shade is provided by umbrella and shaded patio covering, Water pitcher and personnel water bottles are used for drinking water. A review of medication policy, including administering, labeling, storage, and records were made, disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting, and criminal records clearances/exemption transfer requests.

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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: CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300604497
	VISIT DATE: 10/06/2021

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
26
27
28
29
30
31
32

Indoor measurements : Room # 108 : 33'17 x 19'25 = 638'52 - 23'18= 615'35

Total indoor capacity: 615’35 divided by 35 = 17.58 (18 children)

The new added Room # 108 has two sinks and three toilets for the children.

Total sinks and toilets in the facility (Including all the preschool and toddler rooms)

Total sinks= 12x15= 180 / Total toilets = 12 x15=180

Outdoor: Facility is also adding an additional outdoor yard (Outside Room # 108 and 107), this space was also had a temporary COVID Waiver and now is being added to the preschool license.

Outdoor measurements: 46’67 x 45 = 2100’15 (28’12) 28 children.

The new added yard shall be shared between two classrooms (Room # 107 and Room 108)

Facility will submit a Waiver for the new yard for a rotating schedule between the classrooms.

Fire clearance from City of Costa Mesa Fire prevention office has been received on 9/24/21 and approved for 134 preschool age children, total including 12 Toddlers.

Based on today’s indoor measurements, total sinks/toilets and outdoor space, Facility has enough space to accommodate the requested capacity of 122 Preschool children and 12 Toddlers: Total capacity 134 children.

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

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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: CHRIST LUTHERAN PRESCHOOL	FACILITY NUMBER: 300604497
	VISIT DATE: 10/06/2021

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
26
27
28
29
30
31
32

Administrator Ms. Holloway Lisa is current on the required CPR training (6/22).

Report was read to the Facility Administrator and appeal rights were provided and Notice of Site visit was posted.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

Exit interview conducted. Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post it will result in civil penalties of $100. “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.”

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3