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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600164
Report Date: 10/19/2023
Date Signed: 10/19/2023 11:30:36 AM


Document Has Been Signed on 10/19/2023 11:30 AM - It Cannot Be Edited

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:MISSION NAZARENE PRESCHOOL - INFANTFACILITY NUMBER:
376600164
ADMINISTRATOR:EVELYN KENSELFACILITY TYPE:
830
ADDRESS:4750 MISSION GORGE PLACETELEPHONE:
6192874900
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:36CENSUS: 25DATE:
10/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Evelyn KenselTIME COMPLETED:
11:40 AM
NARRATIVE
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On 10/19/23 at 9:15am, Licensing Program Analysts (LPA) Patrick Ma and Martha Avila, visited the facility to conduct a case management site inspection. The purpose of this visit is to follow up on a self-reported incident that occurred on 10/2/23. Upon arrival, LPA met with Director, Evelyn Kensel. Present at the facility were 25 day care infants and 9 staff in 3 rooms. Facility was in ratio.

During the visit, LPA’s toured the infant care rooms, reviewed the food and bottle storage and labeling, reviewed Needs and Services plans, and conducted interviews with staff.

Based on the information gathered, staff S1 incorrectly provided child C1 with a bottle not labeled for them. It was found that the bottles were correctly labeled at the time and that staff member S1 provided the bottle in error.

Exit interview conducted and report was reviewed with the facility representative Evelyn Kensel. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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Document Has Been Signed on 10/19/2023 11:30 AM - It Cannot Be Edited

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: MISSION NAZARENE PRESCHOOL - INFANT
FACILITY NUMBER: 376600164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
101223(a)(2)

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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations…

This requirement was not met as evidenced by:
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Director stated, after the incident they implemented a new proceedural step where staff must verify with a 2nd staff they are porividing the correct bottle to the child before feeding and both the bottle and top of bottle cap is labled with name and date. Deficieny corrected.
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Based on information gather, child C1 was given a bottle to drink that belonged to child C2. Providing a child with a bottle that belongs to another child is a potential risk to their health and safety and/or personal rights.
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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: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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