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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191602269
Report Date: 06/06/2024
Date Signed: 06/06/2024 01:47:03 PM


Document Has Been Signed on 06/06/2024 01:47 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: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: 0DATE:
06/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Josephine MeadeTIME COMPLETED:
01:45 PM
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On 6/6/24 at 11:15am, Licensing Program Analyst (LPA), V. Wheatley conducted a case management inspection and met with the director Josephine Meade. There are no children present today due to In-Service Day. The purpose of the inspection is regarding an incident whereby a 4 year old child was injured on June 4, 2024 at approximately 8:55am.

The child was playing on the main yard. There were 12 children supervised by Staff #1. The child #1 was playing with another child #2 and child #1 injured their arm. The staff provided an ice pack and called the parents. The child was taken to the doctor. The parents informed the staff that the child suffered a sprain and was able to return to school the next day. The child came back to school with a sling. A doctor's note is required for the child to return back to school.

The incident was telephoned to Community Care Licensing on June 4, 2024. The required LIC 624 Unusual Incident form will be submitted to the Department within 7 days.

There are no deficiencies cited today.

Exit interview conducted. A copy of the report was read and provided.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Veronica WheatleyTELEPHONE: (424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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