<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005988
Report Date: 07/14/2021
Date Signed: 07/14/2021 01:56:22 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-KFACILITY NUMBER:
372005988
ADMINISTRATOR:MELBA JIMENEZFACILITY TYPE:
850
ADDRESS:6440 SAINT THERESE WAYTELEPHONE:
(619) 583-1493
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:60CENSUS: 33DATE:
07/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Melba JimenezTIME COMPLETED:
02:00 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
On July 14, 2021 at 12:20 p.m. Licensing Program Analyst, Leilani Curtis, conducted an unannounced inspection to follow up on a self reported incident that occurred on 7/2/2021 wherein a 3 year old child (C1) tripped and fell on the “rubber chips” located beneath the play structure. Upon arrival LPA met with Director Melba Jimenez and proceeded to tour the facility. There were 33 children with 4 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 and the Director. Staff #1 was interviewed via telephone while LPA was on site. The child involved has not signed up for the summer session and has not returned to the facility. On 7/2/2021 at approximately 9:50 a.m. C1 was walking and turning around on the rubber chips underneath the play structure. C1 tripped, fell and hit the right side of his head on the metal pole base of the monkey bars. C1 sustained a cut above his right ear. S1 observed the fall and assisted the child immediately. S1 cleaned the injury and comforted the child. The child’s parent was notified and the C1 was taken to the emergency room where he received one staple where the injury occurred. At the time of the incident there were 20 children present with 3 staff members. Supervision was in place and ratios were met. The facility responded appropriately and reported timely.

The director & LPA toured the playground where the incident occurred. The play structure appears to be age appropriate and there is rubber mulch/chips underneath the structure. On 2/3/21 a previous injury was reported to have occurred in this same area. At that time the director stated that they were going to add additional rubber mulch to better protect the children. The director states that additional rubber mulch was added on 2/10/2021. LPA observed adequate cushioning under the structure. The director also states that after this current incident their maintenance person put foam similar to that of a “pool noodle” on the equipment in the area. LPA observed the foam on the connecting portions of the structure and over the bolts. Although the bolts on the structure have a rubber tip the director will look into other options for covering the bolts on the play structure. The director will send pictures of the covered bolts once completed.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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: ST. THERESE ACADEMY PRE-K
FACILITY NUMBER: 372005988
VISIT DATE: 07/14/2021
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
26
27
28
29
30
31
32
No deficiencies are cited.

An exit interview was conducted with Director Jimenez and Appeal Rights (LIC 9058 1/16) were discussed. The director’s signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed the director post notice of site visit.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2