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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300604497
Report Date: 05/19/2026
Date Signed: 05/19/2026 03:48:15 PM

Document Has Been Signed on 05/19/2026 03:48 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CHRIST LUTHERAN PRESCHOOLFACILITY NUMBER:
300604497
ADMINISTRATOR/
DIRECTOR:		EMILY MARTINEZFACILITY TYPE:
850
ADDRESS:760 VICTORIA STREETTELEPHONE:
(949) 631-1639
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 129TOTAL ENROLLED CHILDREN: 127CENSUS: 99DATE:
05/19/2026
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Facility Representative, Emily MartinezTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 05/19/2026, Licensing Program Analyst (LPA), Deschampe entered the facility at 10:12AM for an unannounced case management inspection for the purpose of an increased capacity request. LPA met with the facility representative/director (FR), Emily Martinez. LPA was led on a tour of the inside and outside of the facility by the FR. The facility is currently licensed to serve Monday-Friday, 6:30AM - 6:30PM, 129 children ages 2-6 years in rooms: 108/Purple, 109/Red, 110/Blue, 111/Green, 115/Yellow, 116/Orange, including 7 toddler option children ages 18-36 months in New Nursery/Pink Room.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility has requested a capacity increase from 7 toddler option children to 18 toddler option children, by re-licensing Room 107/Pink Room. The facility has requested to provide care and supervision for 122 preschool children in Rooms 108/Purple, 109/Red, 110/Blue, 111/Green, 115/Yellow, and 116/Orange with 18 additional toddler option children ages 18-36 months in Pink Room and Room 107/Pink Room, from 6:30AM-6:30PM.

All indoor and outdoor activity space utilized for children was inspected today. Carbon Monoxide detectors were tested and operable in Rooms Green Blue Red and Purple. Smoke Alarm is centralized and tested quarterly by the inspection company and annually by the fire department. Required licensing documents are
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL
FACILITY NUMBER: 300604497
VISIT DATE: 05/19/2026
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posted on the exterior wall, behind the entrance gate to the outdoor play area. Sign in/out is completed by parents/authorized representatives via CareConnect app, using a unique PIN.

LPA confirmed measurement of 2 rooms today (Pink Room and Room 107/Pink Room). Total indoor activity space measured at 1076 square feet (measured by LPA K. Desai on 08/04/2022 and LPA Malek on 08/19/2015), which is sufficient to accommodate the requested overall capacity of 18 toddler children (18-36
months of age). LPA did not observe age-appropriate furniture and equipment, including tables, chairs, cubbies, and cots in Room 107/Pink Room, all other rooms contained age-appropriate equipment and furniture. LPA observed all hazardous items to be inaccessible to children. There are no bodies of water or weapons on the property. LPA observed a total of 10 sinks and 12 toilets available to children. Staff bathrooms are separate and sufficient. Room 107/Pink Room are equipped with a potty chair, changing table and a sink within arm's reach. Pink Room has 1 toilet, 1 changing table and a sink within arm's reach. The isolation area for children who are ill will be the facility's office. The staff bathroom will be designated for sick children's use. Children bring water, snack, and lunch from home.

The outdoor space for toddler children was inspected. The total toddler outdoor space was measured at 3746 square feet and total preschool outdoor space was measured at 9016 square feet (measured by LPA K. Desai on 08/04/2022 and 08/08/2022), which accommodates 18 toddler children and 122 preschool children, respectively. The playgrounds are fully fenced. The surface of the toddler playground is artificial grass. Shade is provided. There are sufficient outdoor age-appropriate toys and play equipment available.

Fire Clearance dated 04/27/2026, has been received from the Fire Department, City of Costa Mesa granting the capacity for 18 toddler children and 122 preschool children.



Based on today's measurement of indoor/outdoor space, and number of sinks and toilets, the facility meets the requirements for the capacity of 122 preschool children (2-6 years old) in rooms 108/Purple, 109/Red, 110/Blue, 111/Green, 115/Yellow, and 116/Orange and 18 toddler children (18-36 months of age) in Pink Room and Room 107/Pink Room. The facility will be granted the increased capacity of 140 preschool children upon final review and approval from management.
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL
FACILITY NUMBER: 300604497
VISIT DATE: 05/19/2026
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The following corrections are needed prior to the issuance of the license:

1. Carbon monoxide detector in Room 107


2. Infant/Toddler furniture and equipment, including cots, etc.

Licensee understands that all proof of corrections must be provided to the Department within 30 days, or the application may be denied.

Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CHRIST LUTHERAN PRESCHOOL
FACILITY NUMBER: 300604497
VISIT DATE: 05/19/2026
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Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

An exit interview was conducted with Facility Representative, Emily Martinez. Notice of Site Visit was posted during the visit. The facility representative was informed that the notice of the site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. First-level appeals should be sent to the regional manager to the address listed above. End of report.
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
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