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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490101372
Report Date: 05/13/2019
Date Signed: 05/13/2019 03:20:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:ST. LUKE LUTHERAN PRESCHOOLFACILITY NUMBER:
490101372
ADMINISTRATOR:GERHARDT, JEANNEFACILITY TYPE:
850
ADDRESS:905 MENDOCINO AVETELEPHONE:
(707) 545-0512
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:48CENSUS: 14DATE:
05/13/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jeanne GerhardtTIME COMPLETED:
03:30 PM
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At 3:00 on 05/13/2019, Licensing Program Analyst (LPA) J. Velasco conducted an unannounced case management inspection to deliver to the facility director (or staff designated by the director) a letter ordering the immediate exclusion of a staff (S1) associated to this facility. Director Jeanne Gerhardt (D) was not present at the facility. Staff called D, who spoke with LPA, said she could not return to the facility in a timely manner, and requested LPA give the Immediate Exclusion letter to S2. LPA provided S2 with the letter and a privacy folder for the letter. LPA also provided S2 with this LIC 809 and the Notice of Site Visit. Notice of Site Visit must be posted for thirty (30) days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2019
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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