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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600736
Report Date: 01/21/2020
Date Signed: 01/21/2020 01:01:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:WEST LOS ANGELES METHODIST PRE-SCHOOLFACILITY NUMBER:
191600736
ADMINISTRATOR:CAROL MAYERFACILITY TYPE:
850
ADDRESS:1637 BUTLER AVETELEPHONE:
3104791682
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY:30CENSUS: 7DATE:
01/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Carol Mayer, DirectorTIME COMPLETED:
10:35 AM
NARRATIVE
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On 01/21/2020 at 08:35 am, Licensing Program Analyst (LPA) Denise Miranda arrived at West Los Angeles Methodist Preschool located at 1637 Butler Ave, CA 90025 for the purpose of following up on the unusual incident that occurred at the facility on 1/09/2020.
LPA met Carol Mayer that was providing care and supervision for 7 children in care.

According to the report that was reported on 01/13/2020, on 1/09/2020, during center time, child#1 was playing outdoor area at the slide area. child#1 moved from slide equipment to the airplane equipment and tripped and hit his mouth on the airplane equipment. Teacher#1 noticed child’s#1 tooth (front) was cracked.

Outdoor equipment was inspected for safety, cushioning material, good repair and age appropriateness, free of sharp, loose or pointed parts. LPA observed shade area accessible to children in care. No body of water was observed at the facility.


During this inspection, LPA conducted interviews with facility staff and reviewed the child's records. LPA was unable to interview the child involved in the incident due to the child is no longer enrolled at the school.

At this time, further investigation is needed.

Deficiencies were observed and Type B citations was issued today, 01/21/2020. See LIC 809-D for deficiency page. Deficiency was cleared during this visit.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Carol Mayer, Director.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: WEST LOS ANGELES METHODIST PRE-SCHOOL
FACILITY NUMBER: 191600736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2020
Section Cited

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Reporting Requirements: Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the
Deparment's next working day and during its normal business hours. In addition, a written report containing the inf. specified in (d) (2)
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... that shall be submitted to the Department within seven days following the occurrence of such event. This requierment is not met as evidenced by: On 1/21/20 LPA observed that the Director did not report to the Dept. the incident that occurred on 01/9/20 in 24hrs. This is a type B violation and it poses a potential risk to the children in care.

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 within the Deparment's next working day and during its normal business hours.

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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: Jennie FerreiraTELEPHONE: (424) 301-3067
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2020
LIC809 (FAS) - (06/04)
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