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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600943
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:39:04 PM


Document Has Been Signed on 05/03/2023 12:39 PM - 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: 69DATE:
05/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Tamara SimpsonTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Warren Birks conducted a Case Management Incident inspection. This inspection is regarding an incident that took place on April 25, 2023. LPA met with Director Tamara Simpson who provided information and assistance during the inspection.

Director Simpson guided LPA to the outdoor area to observe where child #1 was injured. LPA observed the area to appear to be in normal condition (orderly and free of uncommon hazards). LPA also observed the all play equipment appear to be in adequate condition. Director indicated she was approximately 15 feet away observing child l#1 when the injury took place. Child #1 was running and ran into a play house sustaining an injury to the left wrist. Staff #1 indicated staff #1 was not in the vicinity when the incident occurred but observed child #1 running in the direction of the play house. Both Staff indicated the facility was in ratio during the time of incident (at least three or four teachers and 30 to 34 children).

Post injury, Director and staff #1 conducted first aid. A parent arrived at the school and the child was taken to the hospital for minor medical treatment. Child returned to school within 48 hours with no medical restrictions. Staff followed the required protocol in terms of first aid and "reporting requirements" as the 4/25/2023 incident was reported to Child Care Licensing within 24 hours or the next business day. The 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 Simpson.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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