372005988-2-3-2021-51-CC-GCUS-BXVUV9-20210203145445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372005988
Report Date: 02/03/2021
Date Signed: 02/03/2021 02:55:41 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:	ST. THERESE ACADEMY PRE-K		FACILITY NUMBER:	372005988
ADMINISTRATOR:	SUSAN CONLEY		FACILITY TYPE:	850
ADDRESS:	6440 SAINT THERESE WAY		TELEPHONE:	(619) 583-1493
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	60	CENSUS: 54	DATE:	02/03/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Melba Jimenez		TIME COMPLETED:	03:00 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	Covid-19 State of Emergency On February 3, 2021 at 1:15 p.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection via Zoom to follow up on a self reported incident that occurred on 1/28/21 wherein a 5 year old child (Child #1) fell off the “Monkey Bar Structure” and landed on the rubber mulch beneath the structure. LPA met with Director Melba Jimenez and proceeded to tour the facility. There were 54 children with 7 staff members present. Appropriate ratio/capacity were observed. Staff members have the required background clearances and are associated to the facility. LPA interviewed Staff #1, Staff #2, Staff#3 and Child#1. On 1/28/21 at approximately 9:55 a.m. Child #1 was hanging by her hands & feet from a bar on the "Monkey Bar Structure" on the “Tot Lot”. The child slipped, fell and landed on her back on the rubber mulch beneath the structure. The child complained of shoulder pain. Staff tended to the child and applied ice to the shoulder area. The child’s parent was notified and the child was taken to Urgent Care where she was diagnosed with a minor fracture near the right shoulder on the clavicle bone. The child’s arm was placed into a sling. During the incident there were 10 children present with Staff #1 in that area of the playground. Supervision was in place and ratios were met. The facility responded appropriately and reported timely. The parent of Child #1 was contacted immediately. The director & LPA toured the “Tot Lot” where the incident occurred. The play structure appears to be age appropriate and there is rubber mulch underneath the structure. The director states that she spoke with the Principal & Janitor and they will be adding additional rubber mulch to better protect the children.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace Curtis	TELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2021

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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: ST. THERESE ACADEMY PRE-K	FACILITY NUMBER: 372005988
	VISIT DATE: 02/03/2021

NARRATIVE

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No deficiencies are cited.

An exit interview was conducted and appeal rights (LIC 9058 1/16) were discussed. A copy of this report as well as a copy of the appeal rights were emailed to the Director at the conclusion of the inspection. The Director will confirm receipt of this report via e-mail and the reply of confirmation will serve as the signature acknowledging these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace Curtis	TELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2021

LIC809 (FAS) - (06/04)

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