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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197416078
Report Date:
03/15/2022
Date Signed:
03/21/2022 03:11:32 PM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
03/21/2022 03:11 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
39115 TRADE CENTER DR STE. 201
PALMDALE
,
CA
93551
FACILITY NAME:
LANCASTER-JACK NORTHROP ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER:
197416078
ADMINISTRATOR:
FOUNTAIN, KELLY
FACILITY TYPE:
850
ADDRESS:
835 EAST AVENUE K-4
TELEPHONE:
(661) 948-6152
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93535
CAPACITY:
22
TOTAL ENROLLED CHILDREN:
16
CENSUS:
13
DATE:
03/15/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Christina Baldwin
TIME COMPLETED:
05:15 PM
NARRATIVE
1
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SUPERVISORS NAME
:
Mariela Ramon
LICENSING EVALUATOR NAME
:
Lady King
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/21/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/21/2022
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
,
39115 TRADE CENTER DR STE. 201
PALMDALE
,
CA
93551
FACILITY NAME:
LANCASTER-JACK NORTHROP ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER:
197416078
VISIT DATE:
03/15/2022
NARRATIVE
1
2
3
4
5
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8
9
10
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SUPERVISORS NAME
:
Mariela Ramon
LICENSING EVALUATOR NAME
:
Lady King
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/21/2022
LIC809
(FAS) - (06/04)
Page:
2
of
2