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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191602269
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:46:40 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:ST. JOHN'S LUTHERAN CHURCH NURSERY SCHOOLFACILITY NUMBER:
191602269
ADMINISTRATOR:MARY JOSEPHINE MEADEFACILITY TYPE:
850
ADDRESS:1611 EAST SYCAMORETELEPHONE:
(310) 615-0211
CITY:EL SEGUNDOSTATE: CAZIP CODE:
90245
CAPACITY:90CENSUS: 53DATE:
11/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Josephine Meade, DirectorTIME COMPLETED:
03:00 PM
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At 2:00pm Licensing Program Analyst (LPA) Lisa Clayton conducted a case management visit to follow up on an Unusual Incident Report, received on 11/15/2021. LPA was greeted by Mary Josephine Meade, Director. Also present during the inspection was office manager Michelle Reddeg, 8 teachers 53 children in care.

The facility was toured both inside and out for a Health and Safety inspection. LPA Clayton asked to see the area were the incident took place. LPA observed that the playground structure and surface is maintained and in safe condition, with sufficient cushioning underneath to absorb a fall. All other playground equipment appears to be safe, in good repair and there are ample age appropriate toys.

On 11/12/21 at 3:58 pm Child 1 (C1) had an accident on the New Yard Playground. C1 was sliding down the apex climbing structure and the as she felt herself falling, she braced herself with her right arm. The Child sustained a sprain to the right arm. Teacher 3 recommended for the father to take C1 to the doctor. C1 father was called at 3:59 pm and arrived at the school at 4:02 pm and took C1 to the doctor. Father sent a follow up email on Saturday 11/13/21 at 10:00 am notifying the facility that the child did not have a fracture and only had a bad sprain. Director states that C1 can return to school on 11/15/21. Director states that at the time of the incident Teacher 1 observed the accident.

Since the incident, C1 has been attending school regularly, and though she does not like the sling the doctor provided, her arm is wrapped up from her wrist to her forearm with no restrictions. Staff has observed C1 playing and behaving as usual.

Based on LPA observations, LPA Clayton finds that there was appropriate supervision, the climbing structure is secured, age appropriate and used according to the manufacturers instructions.

There are no deficiencies cited during today's inspection. A copy of this report and notice of site visit was provided to Director.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lisa ClaytonTELEPHONE: (424) 301-3206
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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