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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606475
Report Date: 08/23/2019
Date Signed: 08/23/2019 10:21:23 AM

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:KING OF KINGS LUTHERAN CHURCHFACILITY NUMBER:
300606475
ADMINISTRATOR:DAWN GOETZFACILITY TYPE:
850
ADDRESS:13431 NEWHOPE STREETTELEPHONE:
(714) 530-2152
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:20CENSUS: 0DATE:
08/23/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Dawn GoetzTIME COMPLETED:
10:30 AM
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A case management inspection was conducted on this day by LPA Ho. LPA did not observe any children in care due to summer break. The purpose for today's inspection was to measure and inspect the new room. Facility is currently licensed for 24 children in the Preschool Room at the front parking lot and seeking to change to the Preschool room by the playground. LPA toured the entire facility indoors & outdoors and the following measurements were taken:

Indoor:
Preschool classroom: 28'3" x 29'6 = 833'/35' = 24 children

Total children toilets and sinks:
6 toilets x 15 = 90 children
8 sinks x 15 = 120 children

Outdoor:
Total outdoor activity area: 3402.5 sq./75 = 45 children

Base on today’s measurement and the sink & toilet availability, center has sufficient activity space to support the requested capacity of 24 children in the preschool room by the playground.

The following was observed:
· Classrooms are adequately equipped with age and size appropriate furniture and equipment
· Water dispensers will be available for inside drink and water jug will be available for outside drink.
· Playground is enclosed by appropriate fence.
· Outdoor activity area is supplied with age and size appropriate equipment
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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 2
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: KING OF KINGS LUTHERAN CHURCH
FACILITY NUMBER: 300606475
VISIT DATE: 08/23/2019
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. Adequate shade is provided by canopy.
· Children bring their own food.
· The Book area will be used as the isolation area for ill children until parents arrive.
· Medication will be stored in the office/kitchen and is inaccessible to children.
· Medication administration forms were reviewed.
· First Aid kit is complete.
· Sign in/Sign out record was reviewed and meets regulation requirements

No deficiency observed during today's inspection.

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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
LIC809 (FAS) - (06/04)
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