Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607186
Report Date: 10/21/2016
Date Signed 10/21/2016 02:21:25 PM

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:UNITED METHODIST CHURCH OF GOOD SHEPHERDFACILITY NUMBER:
300607186
ADMINISTRATOR:ANA FLORESFACILITY TYPE:
840
ADDRESS:8152 MCFADDEN AVENUETELEPHONE:
(714) 894-4330
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:60CENSUS: 0DATE:
10/21/2016
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Director Ana FloresTIME COMPLETED:
03:00 PM
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A case management visit was conducted on this date by LPA Ho. The purpose for today’s visit was to evaluate the facility for a capacity decreased. Facility is currently licensed for 60 children and requesting to decrease capacity to 24 children. The Wesley Hall room is no longer used by school-age program. Aldergate and Good Shepherd Youth rooms are the only 2 rooms being used by the school-age program. LPA met with director Ana Flores and toured the facility. No children present. Children will be arriving at 2:30pm.

All areas identified on the Facility Sketch were inspected. Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Storage for children's belongings and an isolation area with sink, toilet, and mat/cot were inspected. Availability of drinking water was reviewed. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, area safety and sanitation. First Aid supplies were inventoried. A review of medication policy, including administering, labeling, storage, and records were made, disaster drills, posting requirements, children records, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby

Measurements are taken as follows:

Indoor space:

Aldergate Room: 23'8 x 15'8 = 370' divided by 35' = 11 children
Good Shepherd Youth Room: 27'10 x 17' = 473' divided by 35' = 14 children

Toilets: 5 x 15 = 75 children
Sinks: 3 x 15 = 45 children
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2016
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: UNITED METHODIST CHURCH OF GOOD SHEPHERD
FACILITY NUMBER: 300607186
VISIT DATE: 10/21/2016
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Outdoor space:
150' x 135' = 20250' divided by 75 = 270 children.

Based on today’s measurements, facility will be decreased to 24 children.

Director stated the Wesley Hall room will be used by the Vietnamese Tutoring Program. Their program starts from 3 to 6pm Monday to Thursday. The children from the Tutoring program will be using the woman and men restrooms in the church office. Director stated she will make sure the school-age children are not combined with the children from the Tutoring program at any time.

After a tour of the center, no deficiency was observed .

Web address for downloading forms or regulations was provided as (http://ccld.ca.gov/PG411.htm).

Exit interview conducted. Notice of Site Visit was posted. Director was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post it will result in civil penalties of $100.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2016
LIC809 (FAS) - (06/04)
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