304371036-2-12-2021-06-CC-ECOL-BY6SU2-20210212131025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371036
Report Date: 02/12/2021
Date Signed: 02/12/2021 01:11:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	CHRIST LUTHERAN CHURCH- PRESCHOOL		FACILITY NUMBER:	304371036
ADMINISTRATOR:	SUSAN ILTEN		FACILITY TYPE:	850
ADDRESS:	820 W. IMPERIAL HWY		TELEPHONE:	(714) 529-0892
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	44	CENSUS: 0	DATE:	02/12/2021
TYPE OF VISIT:	Case Management - Incident	ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Director - Susan Itlen		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Tele-Investigation due to COVID-19 State of Emergency On 02/08/2021 Licensing Program Analyst (LPA) Corral spoke to Director Susan Itlen to investigate an Unusual Incident Report (UIR) which was self reported to our office on 01/14/2021. LPA Corral notified the Director that due to COVID-19 and Department of Public Health (DPH) guidelines of Social Distancing an on-site inspection would not be conducted. During our phone investigation Director Susan Itlen and Teacher Marisela Vazquez were present. According to the self reported incident sent to our office, a child (C1) collided with another child (C2) on the playground, C1 fell and hit her chin in the bottom of a slide. The UIR states Ms. Vazquez witnessed the incident and applied compressions to stop the bleeding. According to the UIR, C1 parents were called and arrived at the facility within 5 minutes of the incident. C1 was taken to CHOC by parents where ¼ inch stitches were applied. According to the UIR C2 did not obtain an injury. C1 returned to school on 01/21/2021, with no medical restrictions. LPA Corral interviewed Director Susan via phone investigation on 02/08/2021. During the interview Director stated the Staff present during the incident provided a hard copy of the ouch report to C1’s mother. Director stated she requested the Doctor’s Note from Child’s mother, but it was not provided. Director also stated both children were running towards each other, one from each side and they collided. The slide where the injury occurred has rounded corners and no sharp edges. Director also informed LPA Corral there is thick padding underneath the new play equipment. Director stated the incident was unavoidable and could not have been prevented as both C1 and C2 were playing and accidentally ran into each other. Director Susan stated this was an accident as it was innocent play between two children. Continue to LIC 809C, Page 2.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen Corral	TELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHRIST LUTHERAN CHURCH- PRESCHOOL	FACILITY NUMBER: 304371036
	VISIT DATE: 02/12/2021

NARRATIVE

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LPA Corral also interviewed the staff member that was present during the Incident, the Staff stated she was a few feet away from the slide and C1. Staff informed LPA Corral that right after the incident occurred, she walked over to both children and saw blood on C1, while C2 was fine and had no markings. Staff also stated she took C1 to the bathroom to get paper towels to stop the bleeding. Staff informed LPA Corral that she immediately called C1's parents while she was helping child with the bleeding. LPA Corral also spoke to the Child’s mother on 02/09/2021 and all information provided by Director and Teacher was confirmed.

On 02/12/2021 LPA Corral conducted a Tele- inspection via Zoom to provide findings for the self reported Unusual Incident Report received in our office on 01/14/2021. LPA notified the Director that due to COVID-19 and Department of Public Health (DPH) guidelines of Social Distancing a Tele-Inspection would be conducted. The COVID-19 Emergency Response questions were asked. During the Tele-Inspection there were no children present, 1 staff was present in the facility. A review of the Facility Personnel Report Summary on 02/12/2021 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Due to the information obtained from the Director, Teacher, and Parent Interview, this incident was an accident as it was innocent play between two children. Based on photographs received the slide where the injury occurred has rounded corners and does not have sharp edges, there is also thick padding underneath the play equipment. Based on the interviews conducted throughout the investigation, it was determined an accident did occur, however the incident was not preventable as the teacher observed the incident, and immediately rendered first aid treatment. Therefore, the facility was within compliance of the Title 22 Regulations, facility is not being cited during today’s Tele-Inspection.

The Notice of Site Visit was not posted due to Tele-Investigation COVID-19 State of Emergency. Appeal Rights were explained. A copy of the Evaluation Report and Appeal Rights (LIC 9058 1/16) will be provided through email and signature on this report acknowledges receipt of these rights. (The "Read Receipt" is in lieu of a signature). Director was informed first level appeal is directed to Regional Manager. Exit interview was conducted.

End of Report.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Eileen Corral	TELEPHONE: (714) 743-8354
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

LIC809 (FAS) - (06/04)

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