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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334830693
Report Date: 06/16/2020
Date Signed: 06/17/2020 01:02:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:ST THOMAS EPISCOPAL PRESCHOOLFACILITY NUMBER:
334830693
ADMINISTRATOR:SANDRA GUAJARDOFACILITY TYPE:
850
ADDRESS:44651 AVENIDA DE MISSIONESTELEPHONE:
(951) 302-8498
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:90CENSUS: DATE:
06/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:SANDRA GUAJARDOTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sean Williams made an unannounced phone call to ST. THOMAS EPISCOPAL PRESCHOOL for the purpose of following up on a (UIR), Unusual Incident Report, regarding a child that was left unattended for 2 1/2 minutes in the restroom by facility staff. LPA Williams spoke with Director, Sandra Guajardo and interviewed all other relevant individuals pertinent to this incident.

During the investigation, it was learned that a facility staff member escorted a child to the restroom from the playground. It was explained by facility staff, that there are two doors that can be used to access the children's restroom, one door to the playground and the other through the "busy bee" classroom. The staff member that escorted the child stated that once they believed the child was finished using the restroom, the staff member stepped in the restroom, looked around, and called out the child's name. The staff member stated that there was no answer, so they closed the restroom door to the playground without physically checking to ensure the child was finished using the restroom. It was reported, that approximately 2 1/2 minutes later, the child came out of the restroom through the "busy bee" classroom entrance to the facility. It was also reported that the child was crying due to being in the restroom without supervision.

Due to the facility staff member not physically checking on the child to ensure the child was finished and safely escorted back to the playground, placed the child at risk. This is a case of absence of supervision. This deficiency shows a lack of supervision on the part of a facility staff member on this occasion. This is a violation of Title 22 Regulations by the facility staff regarding this incident. The violation is: (101229 (a)(1) (Responsibility for Providing Care and Supervision) (SEE LIC809D CITED DURING THIS TELE- INSPECTION.)

(CONTINUED ON THE NEXT PAGE)
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Sean R WilliamsTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: ST THOMAS EPISCOPAL PRESCHOOL
FACILITY NUMBER: 334830693
VISIT DATE: 06/16/2020
NARRATIVE
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This report was completed via Tele-Inspections Report Delivery Instructions. Licensee's signature will be obtained via email.

A NOTICE OF SITE VISIT WAS NOT LEFT AT THE FACILITY DUE TO THIS BEING A TELE- INSPECTION.
Licensee's signatures will be obtained via email. Licensee will receive a copy of this report via email. This report must be made available to the public upon request for the next 3 years
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Sean R WilliamsTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: ST THOMAS EPISCOPAL PRESCHOOL
FACILITY NUMBER: 334830693
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2020
Section Cited

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101229(a) Responsibility for Providing Care and Supervision
(a) 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>>>>>
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>>>(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement was not met as evidenced by staff # 2 leaving the child in the restroom without making sure the child was finished using the restroom and safely escorting the child back to the playground, which put the child at risk without proper supervision.
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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: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Sean R WilliamsTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3