<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367750023
Report Date: 08/01/2019
Date Signed: 08/01/2019 12:29:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:APPLE VALLEY CHRISTIAN ACADEMYFACILITY NUMBER:
367750023
ADMINISTRATOR:PLANTENGA, SHERYLFACILITY TYPE:
840
ADDRESS:15757 ST. TIMOTHY RDTELEPHONE:
(760) 813-3236
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:20CENSUS: 0DATE:
08/01/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sheryl Plantenga, DirectorTIME COMPLETED:
12:40 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
Licensing Program Analyst (LPA) Maddox and Mabika conducted a 2nd Pre-Licensing Inspection today at the Apple Valley Christian Academy which is located on the grounds of St. Timothy's Episcopal Church. LPA's met with Sheryl Plantenga, Director, and Bonnie Cambridge, Asst. Director/Pre-School Teacher. Together we toured and measured the 1 classroom designated for the school age program. Center has also submitted and application for a Pre-School component (X 367750022) in Room #'s 1 and 2. This classroom will be occupied by older pre-school age children (ages 4 to 5 yr olds) from the hours of 8 am to 3:30 PM, after 3:30, center has requested a waiver for this classroom to be occupied by school age children (ages 6 and up) after school. During this inspection, LPA's reviewed some information that need correcting and/or revising in the application, and measured classroom # 3 and play yard. Measurements were as follows:


SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2019
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, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: APPLE VALLEY CHRISTIAN ACADEMY
FACILITY NUMBER: 367750023
VISIT DATE: 08/01/2019
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
Rm #3: 17.02 X 30.03 = 521.31/35 = 15
*The bathroom has 1 toilet and 1 sink = 15 children
Outdoor play yard measured: 87 X 63 = 5,481/75 = 73
Fire Clearance has been approved for 20 children

*School-age children will utilize bathroom located across the play yard, children will be escorted by staff persons to this bathroom.

LPA's are requesting some type of padding be placed on a structure beam located within the classroom. With measurements taken, the school age component can accommodate 15 school age children.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 789-6952
LICENSING EVALUATOR NAME: Donna MaddoxTELEPHONE: (661) 568-8971
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2