Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607186
Report Date: 02/07/2018
Date Signed 02/07/2018 03:32:01 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: 12DATE:
02/07/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Director Ana FloresTIME COMPLETED:
04:00 PM
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(3) An Annual/Random visit was conducted on this date by LPA Ho. Upon arrival LPA met with director, Ana Flores and toured the facility. LPA observed 12 school-age children with 3 staff including the director was playing outside.

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.

After a tour of the center and review of children's and staff records, no deficiency was observed.
Web address for downloading forms or regulations was provided as (http://ccld.ca.gov/PG411.htm).
Exit interview was conducted. The 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 will result in civil penalty of $100.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2018
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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