Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607186
Report Date: 02/15/2017
Date Signed 02/15/2017 04:09:47 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:24CENSUS: 10DATE:
02/15/2017
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Director Ana FloresTIME COMPLETED:
04:30 PM
NARRATIVE
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A case management visit was conducted on this date by LPA Ho. The purpose for today's visit was to confirm school-age children are not commingling with the children at the tutoring center next door. Upon arrival LPA met with teacher, Roxanne Valencia and toured the facility. Director arrived 25 minutes later to meet LPA. LPA observed 10 school-age children with 1 staff having outside play. LPA inspected the following areas: availability of drinking water, age appropriate sinks and toilets, water temperature, toilet paper, paper towels, medication policy, storage areas for poisons and furniture & equipment, food preparation areas, cleaning and food supply storage areas, outdoor equipment (safety, cushioning material, good repair, and age appropriateness, required shade, drinking water and fencing), play area (hazards and inaccessibility to bodies of water), teacher child ratios (staff names recorded), care and supervision, sign in and out sheets. A review of children’s & Staff records were reviewed to identify that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also observed Health Screenings and verification of CPR/First Aid and Preventative Health Practices.
Outdoor activity space surface was observed to have candy wrapper, empty bottles, tree branches, and soiled socks. Part of the Indoor carpet in Aldergate room was detached from the floor.
Any proposed changes to the physical plant, including telephone number, or change of address shall be immediately reported to the Department.
After a tour of the center, review children and staff's records, the following deficiencies were observed and cited in accordance to California Code of Regulation Title 22. Please refer to attached 809D for documentation of deficiencies.

Exit interview was conducted. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalty of $100. , “The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.”
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2017
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2017
Section Cited
101238.2(d)(2)
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Outdoor Activity Space. Outdoor activity space shall be hazard free. Candy wrapper, empty bottles, tree branches, and soiled socks observed on the playground.
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Children helped staff clean the playground on this day. Director stated she will send LPA a written plan making sure the playground is free from hazard before allowing children to play.
Type B
02/17/2017
Section Cited
101238.3(b)
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Indoor Activity Space. All floors shall be safe and clean. Part of the Indoor carpet in Aldergate room was detached from the floor.
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Director stated the church is in the process of removing the old carpet and installing new floor. Director stated she will put a table over the detached carpet to prevent potential tripping hazardous.
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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: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2017
LIC809 (FAS) - (06/04)
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