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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191602269
Report Date: 02/09/2023
Date Signed: 02/10/2023 08:35:04 AM


Document Has Been Signed on 02/10/2023 08:35 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, 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: 49DATE:
02/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary Josephine MeadeTIME COMPLETED:
02:30 PM
NARRATIVE
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On 2/9/23 at 11am, Licensing Program Analyst (LPA), V. Wheatley conducted a case management inspection and met with the director Mary Josephine Meade and Church President Karina Walsh regarding an incident whereby a 4 year old child wandered out of the facility on February 1, 2023 at approximately 1:15pm.
The child #1 was found by an adult passerby who returned the child to the staff unharmed. The police and the child's parents were contacted. The director reported the incident on February 1, 2023 by telephone to Community Care Licensing and submitted LIC 624 Unusual Incident form to the Department. The director conducted her own investigation by reviewing cameras.

The facility is cited for Lack of Supervision and assessed a civil penalty of $500.00. See LIC 9099D.

A copy of this report must be given to every parent that has a child enrolled in addition to every new parent within the next 12 months. The parents will sign a LIC 9224 form. .

Exit interview. A copy of this report will be provided via email.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Veronica WheatleyTELEPHONE: (424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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Document Has Been Signed on 02/10/2023 08:35 AM - 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: ST. JOHN'S LUTHERAN CHURCH NURSERY SCHOOL
FACILITY NUMBER: 191602269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited

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Responsibility for Providing Care and Supervision-The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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The director agrees to submit the following POC: Meeting with staff regarding new supervision protocols and signatures. 2) submit a written plan of all of the corrections including reinforcing the gates 3) Staff count the children every 30 minutes. 4) Director and staff view the Department videos on CCL Website and document their understanding of supervison. The plan will be submitted via via email to LPA Wheatley by 2/13/23
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The deficiency is evidenced by: Child #1 exited the facility by walking out of four gates that were left open. The child was found walking down the street by a passerby. The child was brought back to the facility unharmed. This poses an immediate health, safety risk to persons in care.
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https://ccld.childcarevideos.org/family-child-care-providers/supervising-children

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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: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Veronica WheatleyTELEPHONE: (424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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