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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370805022
Report Date: 06/05/2019
Date Signed: 06/05/2019 05:21:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
370805022
ADMINISTRATOR:REXANNA BLASFACILITY TYPE:
850
ADDRESS:3967 PARK BLVDTELEPHONE:
(619) 299-2890
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY:80CENSUS: 41DATE:
06/05/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Rexanna BlasTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Selina Siao conducted an unannounced case management inspection to follow-up on an incident that occurred on 05/15/2019. At approximately 5:33pm, a 2 year old child was left alone at the playground. The incident was self-reported to Community Care Licensing within the required 24 hours by the Director and the written unusual incident report was received within the seven days requirement on 05/21/2019.

Staff members were interviewed and based on information obtained, it is confirmed that during the incident the facility had 5 children at the playground. Information gathered that a staff member was at the playground supervising 5 children and one child needed to use the restroom. Staff gathered the children after cleaning up and had the children lined up and did a headcount inside the gated playground. Staff had the children proceeded to walk out the playground gate while checking the driveway alley to ensure it's safe. Staff stated that she then locked the playground gate and took the group of children across the driveway alley into the preschool courtyard. She did another headcount in the courtyard and noticed that one child was missing. Staff immediately returned to unlock the playground gate and retrieve the child. Based on all information gathered, the two year old child was left alone without supervision at the playground for less than two minutes.

Appropriate teacher to child ratio was maintained during today's visit. Civil penalty of $250 will be assess today as it's a repeat violation within the last 12 months regarding lack of care and supervision.
See Lic 809D for deficiency cited today:

“Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. “
Appeal Rights (1/16) were discussed and provided. Signature at the bottom of this report confirms receipt. Notice of Site Visit was posted during this visit and will remain posted for 30 days.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 370805022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2019
Section Cited
CCR
101229(a)(1)
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The licensee shall provide care and supervision as necessary to meet the children's needs. 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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Director stated that after the incident two staff member will be at the facility to bring the children from the playground during transitions. There will be two staff at the faciity during closing time at all times. On 5/22/19, training was provided
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This requirement is not met. On 5/15/2019, 2 year old day care child was left alone at the playground for less than 2 minutes while the rest of the children and staff had left to walk across the dirveway alley into the preschool courtyard. This poses an immediate health and safety risk to clients in care.

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with staff members regarding center procedure on transitions and supervision. A copy of thestaff members sign in sheet and the agenda will be submitted to Analyst by 06/06/2019.
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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: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2019
LIC809 (FAS) - (06/04)
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