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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300229
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:24:30 AM

Document Has Been Signed on 07/27/2023 11:24 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:GRACE LUTHERAN CHURCH AND CHRISTIAN SCHOOLFACILITY NUMBER:
376300229
ADMINISTRATOR:BREANNE MANATAFACILITY TYPE:
830
ADDRESS:643 W 13TH AVENUETELEPHONE:
(760) 747-3029
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 13DATE:
07/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Darlene BeebeTIME COMPLETED:
11:35 AM
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On July 27, at 11:05 AM Licensing Program Analyst(LPA) Courtnee Peebles arrived at the facility to conduct a case management visit. LPA toured the facility inside and out and took a census. LPA arrived at the facility to deliver an amended 809D for an annual visit conducted on 07/12/2023.LPA Peebles did not observe immunization for C4, however C4's immunization were in her file attached to another document. A corrected form was given today.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Courtnee Peebles
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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