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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600943
Report Date: 06/15/2022
Date Signed: 06/15/2022 10:10:06 AM


Document Has Been Signed on 06/15/2022 10:10 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:BETHANY LUTHERAN CHURCH PRESCHOOLFACILITY NUMBER:
191600943
ADMINISTRATOR:TAMARA SIMPSONFACILITY TYPE:
850
ADDRESS:4644 CLARK AVETELEPHONE:
(562) 429-7335
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:81CENSUS: 52DATE:
06/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Tamara SimpsonTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management Incident inspection. This inspection is regarding an injury/incident that took place on June 3, 2022. LPA met with Director Tamara Simpson who provided information and assistance during the inspection.

During the inspection LPA interviewed Staff #1 and Staff #2. Staff #1 guided LPA to the playground area where child #1 was injured. LPA observed the area to be clean, free of abnormal hazards and appearing to be in safe good condition. LPA also observed the playground equipment to be an age appropriate. Per staff there were four staff caring for 17 children which is within Title 22 ratio.

Note: The child was taken to the doctor for medical treatment and returned to school June 7th with some restrictions. Staff followed the required protocol in terms of first aid and "reporting requirements". The 6/3/2022 (reported after hours) incident was reported to Child Care Licensing within the required 24 hours or next business day. Information provided matches the incident report. Based on interviews and observations there were no violations of Title 22 requirements.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Director Tamara Simpson.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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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