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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372006473
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:54:25 AM

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:COMMUNITY LUTHERAN PRESCHOOLFACILITY NUMBER:
372006473
ADMINISTRATOR:LORI HASKELLFACILITY TYPE:
850
ADDRESS:3575 E. VALLEY PARKWAYTELEPHONE:
(760) 739-8649
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:120CENSUS: 44DATE:
12/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lori Haskell, DirectorTIME COMPLETED:
12:05 PM
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On the date and time listed, Licensing Program Analyst (LPA) Nasha King arrived at the facility to conduct a Case Management-Incident follow-up on an Unusual Incident Report (UIR) dated 11/19/2021 that was submitted to the Department. LPA King met with Lori Haskell (Director) to discuss the incident.

The Director reported the following incident:
On November 18, 2021, it was reported that C1 fell while playing on a yard structure. C2 pushed C1’s hand (while climbing) and C1 dropped to the sand and hit their head on the structure base.

After speaking with the Director, and the teacher (S1) who was on the yard when the incident occurred, LPA King determined that the incident did not occur due to a lack of supervision. C1 and C2 were playing a game when the incident occurred. S1 immediately attended to C1 to assess them for injuries.

LPA King has also determined that facility staff took the necessary steps to ensure the health and safety of the children in care, as both the Director and the teacher assessed C1’s injuries and notified C1’s parents immediately following the incident. C1 was taken the front office were they was monitored after the incident while awaiting to be picked up.

***Please see LIC 809C for a continuation of this report.***
SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Nasha KingTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: COMMUNITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 372006473
VISIT DATE: 12/13/2021
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Based on the information gathered, there appears to be no violations of Title 22 Regulations found at this time. An exit interview was conducted, and a copy of this report was provided to the Director, Lori Haskell

No deficiencies were cited during this inspection and a Notice of Site Visit was issued and shall remain posted for 30 days.

SUPERVISOR'S NAME: Carlos MartinezTELEPHONE: (951) 782-4950
LICENSING EVALUATOR NAME: Nasha KingTELEPHONE: (951) 204-2046
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC809 (FAS) - (06/04)
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