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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602027
Report Date: 04/01/2021
Date Signed: 04/01/2021 11:43:01 AM

Document Has Been Signed on 04/01/2021 11:43 AM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SALEM LUTHERAN PRESCHOOLFACILITY NUMBER:
300602027
ADMINISTRATOR:VICKERS, KATHYFACILITY TYPE:
850
ADDRESS:6411 EAST FRANK LANETELEPHONE:
(714) 639-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 75TOTAL ENROLLED CHILDREN: 0CENSUS: 47DATE:
04/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kathy VickersTIME COMPLETED:
12:00 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
 ****Tele-Inspection***

Licensing Program Analysts (LPA ) Mila Quinto conducted a case management tele-inspection to the above facility due to a deficiency discovered during a tele-inspection. LPA met with Director, Kathy Vickers. Census was taken. A review of the Facility Personnel Report Summary on this date (4/01/21)indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. However, staff member Taylor Faust has a clearance but is not associated to the facility. The director stated, a request to associated was faxed to the Orange Office on 01/13/20, however the director does not have proof of fax receipt.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 discussed and cited at the time of the visit. The following violation was observed and cited today: Criminal Record Clearance 101170(f) (see LIC 809D).



An exit interview conducted with director. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2021
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 2
Document Has Been Signed on 04/01/2021 11:43 AM - It Cannot Be Edited


Created By: Mila Quinto On 04/01/2021 at 11:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SALEM LUTHERAN PRESCHOOL
FACILITY NUMBER: 300602027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2021
Section Cited
CCR
101170(f)

1
2
3
4
5
6
7
101170(f) Criminal Record Clearance
A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another,... by providing the following documents to the Department:
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The director willinform the HR dept to sign up of for guardian and submitted a request to associate Taylor Faust. The facility is closed is closed for spring break from 4/2/21- 4/9/21. Director will provide proof by 4/12/21.
8
9
10
11
12
13
14
Based on interview, the facility failed to follow up with licensing in associated Taylor Faust to the facility.
This poses a potential safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Mila Quinto
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2