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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191602186
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:37:06 PM


Document Has Been Signed on 06/23/2022 03:37 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:MALIBU METHODIST CHURCH NURSERY CENTERFACILITY NUMBER:
191602186
ADMINISTRATOR:KIRSTEN BOWMANFACILITY TYPE:
830
ADDRESS:30128 MORNINGVIEW DR.TELEPHONE:
(310) 457-5144
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:12CENSUS: DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:TIME COMPLETED:
03:46 PM
NARRATIVE
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On 06/23/22 at 8:57 a.m., Antonio Almanza, Licensing Program Analyst (LPA), conducted an unannounced Annual Required Inspection for the infant license. LPA met with Kirsten Bowman, Director, and toured the facility indoors and outdoors. The facility operates Monday through Friday from 7:45 a.m. to 4:30 p.m.

The facility consists of a sleeping room, a large room that is partitioned with furniture and small kitchen. Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Floors in the facility are clean and safe. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. Solid waste storage containers have tight-fitting covers and are in good repair. The facility is free of flies, insects, and rodents. There is a working smoke detector and carbon monoxide detector in the main room.

Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. There is artificial turf in the playground and large trees that provide shade. Capacity and limitations as specified on the license are being maintained.

At least one person trained in CPR and Pediatric First Aid is present. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. There is a ratio of one teacher supervising no more than four infants in care.

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SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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Document Has Been Signed on 06/23/2022 03:37 PM - It Cannot Be Edited

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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101218.1(c)
Admission Procedures and Parental and Authorized Representative's Rights
(c) The licensee shall post the PUB 393 (8/02), Child Care Center Notification of Parents' Rights Poster in a prominent, publicly accessible area in the child care center at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having PUB393 Child Care Center Notifications of Parent Rights accessible to parents during pick up and drop off, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will place the PUB 393 where parents can have access to it. and provide LPA with photograph.
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the licensee does not have records of disaster drills conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will complete disaster drill log and provide LPA a copy.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2022 03:37 PM - It Cannot Be Edited

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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(1)
Responsibility for Providing Care and Supervision for Infants
(1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. Under no circumstances shall ANY infant be left unattended.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that staff 1 walked outside leaving child 8 sleeping in crib alone in the room, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will provide staff memo about safe sleep regulation and proper supervision; and provide LPA a copy of memo.
Type B
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having a log for every 15 minutes check, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will provide staff memo and create sleeping log; and provide LPA a copy of memo and log.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2022 03:37 PM - It Cannot Be Edited

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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(B)(3)(a)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: (3) Infants up to 12 months of age who are sleeping in a position other than on their back. (a) If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, staff shall return the infant to their back for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having LIC9227 on file for Child 8, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will have the parents of child 8 complete LIC9227 and provide LPA a copy.
Type B
Section Cited
CCR
101430(a)(3)(C)
Infant Care Activities
(C) An infant shall not be swaddled while in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in that staff are reporting they swaddle sleeping infants, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will provide staff a memo on Safe sleep regulation and provide LPA a copy.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10


Document Has Been Signed on 06/23/2022 03:37 PM - It Cannot Be Edited

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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that Volunteer does not immunization's record on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will have gather immunization's form all volunteers prior to volunteering.
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in child 8 does not have LIC 9227 on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will have parents complete LIC9227 and provide LPA a copy.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10


Document Has Been Signed on 06/23/2022 03:37 PM - It Cannot Be Edited

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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101427(j)
Infant Care Food Service
(j) Bottles, dishes and containers of food brought by the infant's authorized representative shall be labeled with the infant's name and the current date.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that containers and bottles in the refrigerator are not labeled with the date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will provide staff and parents a memo of proper food labeling and provide LPA a copy.
Type B
Section Cited
HSC
1596.8662(b)(1)
1596.8662 Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of 3 staff do not have current Mandated Reporter training certificate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director will have the 3 staff complete the training and provide LPA with copy of certifications.

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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 6 of 10


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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186
VISIT DATE: 06/23/2022
NARRATIVE
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LPA reviewed 8 files for 8 children present and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child, medical assessment, individual feeding plan, and Infant Needs and Services Plan. LPA reviewed 3 staff files for 3 staff present and observed files were complete with health screening, immunization records for influenza, pertussis and measles. Staff records contain documentation of meeting qualification requirements.

Each crib, mat or cot is occupied by only one infant at time. LPA observed 5 cribs with draped Muslin Blankets and staff report that they use them to cover and swaddle sleeping infants. Staff physically checks on sleeping infants every fifteen minutes but do not document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Individual Infant Sleeping Plan is not completed and on file for each infant up to 12 months of age (infant #8).

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


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SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10
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: MALIBU METHODIST CHURCH NURSERY CENTER
FACILITY NUMBER: 191602186
VISIT DATE: 06/23/2022
NARRATIVE
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Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D).

1. Food Service - Type B: 101427(j) - Bottles, dishes and containers of food brought by infant’s parents are not labeled with current date.
2. Children Records - Type B: 101419.2(b)(2) - Child 8 does not have infant sleeping plan LIC9227 on file.
3. Staff Records - Type B: 1596.8662(b)(1) - Staff 1, 2, & 3 do not have current mandated reporter training on file.
4. Staff Records - Type B: 1596.7995(a)(1) - Staff 4 is a volunteer in the facility and does not have immunization's on file.
5. Care and Supervision - Type B: 101430(a)(3)(C) - Staff are reporting that they swaddle infants for sleeping. LPA observed 5 cribs with a thin blanket draped over the side to use when infants go to sleep.
6. Care and Supervision - Type B: 101429(a)(2)(B)(3)(a) - There is one 3-month-old Infant in care, facility does not have infant sleeping plan for the infant.
7. Care and Supervision - Type B: 101429(a)(2)(B) - Facility staff are reporting that they check infants every 15 minutes but do not document on a log when they check.
8. Care and Supervision - Type B: 101429(a)(1) - Infant child was left unattended sleeping in a crib while the teacher went outside. LPA observed the teacher outside, the teachers stated she just went outside for a quick moment.
9. Physical Plant - Type B: 101174(d)(2) - Facility does not a have Disaster Drills documented/log.
10. Physical Plant - Type B: 101218.1(c) - PUB 393, Child Care Center Notification of Parents Rights is not posted in the facility in an accessible location to parents during drop of and pick up.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the facility representative Kirsten Bowman.

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SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 9 of 10