376700649-4-30-2019-20-CC-VWIN-BBQUGQ-20190430153443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376700649
Report Date: 04/30/2019
Date Signed: 04/30/2019 03:34:54 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. JOHN'S EVANGELICAL LUTHERAN CHURCH PRESCHOOL		FACILITY NUMBER:	376700649
ADMINISTRATOR:	DAVIDSON, TRACY L		FACILITY TYPE:	850
ADDRESS:	1430 MELODY LANE		TELEPHONE:	(619) 749-2605
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	44	CENSUS: 37	DATE:	04/30/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Tracy Davidson		TIME COMPLETED:	03:45 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	Licensing Program Analyst (LPA) Vicky Williamson arrived at the facility to conduct a case management inspection to follow up on incident reports that occurred on 12/3/18 and 4/4/19. LPA met with Director, Tracy Davidson. There were 37 preschool children present with 5 staff members. On December 5, 2018, the director self- reported an incident of possible lack of supervision violation that allegedly occurred on 12/3/18. On December 3, 2018, child #1 was running and playing with two other day care children on the playground in the blacktop area. Staff #1 observed the children playing and noticed that they were running. Staff #1 stated that she immediately told the children to stop running and turned away to assist two children in the bike area who had bumped into each other while riding their bikes. Staff #1 stated that at that time she believes that child #1 fell down and hurt herself. Staff #1 states that child #1 was brought over to her by child #1 and child #2 and she was advised by both children that child #1 fell and hurt her head. Child #1 cried but returned to the playground and continued to play. Staff #1 states that she did not observe any injury to the forehead or anywhere else on the child's body. Staff #1 acknowledged that she did observed a mark on the forehead later in the day on 12/3/18, but thought that it was a mark from a marker and not an injury. The parents of child #1 were not contacted by facility staff and were not provided an ouch report due to staff #1 was not aware of an injury until notified by the child’s parent during pick-up. Per director, child #1 had to seek medical treatment. LPA conducted interviews with the directors, child #1 and staff members. Child #1 disclosed that she was running and playing with her friends when she fell onto the blacktop. Child #1 returned to the facility on 12/5/18. LPA reviewed records, obtained a copy of related documentation and facility roster. Based on the evidence obtained, it has been determined that staff #1 failed to provide adequate supervision to child #1 resulting in the child sustaining an injury that went unnoticed.

SUPERVISOR'S NAME: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2019

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. JOHN'S EVANGELICAL LUTHERAN CHURCH PRESCHOOL	FACILITY NUMBER: 376700649
	VISIT DATE: 04/30/2019

NARRATIVE

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On April 5, 2019, the director self- reported an incident of possible lack of supervision violation that allegedly occurred on 4/4/19.

On April 4, 2019, at approximately 10:30 am on the playground child #1 fell on the ground onto the wood chips near the play structure. Director stated that there were two teachers, one parent volunteer and approximately 13 children present on the playground when the incident occurred. Staff members present stated that they did not observe child #1 fall from the play structure onto the wood chips. Staff #1 stated that she observed child #1 on the ground near the play structure with his hands stretched outward and laying on his stomach. Staff #1 stated that the child cried but that there was no indication that the child sustained an injury or where the child fell from. Staff #2 is the child's teacher but was not present on the playground during the incident. Staff #2 noticed that child #1 continued to cry throughout the day. Staff #2 comforted the child assuming that child #1 was tired and cranky. Staff #2 stated that there was no indication of child #1 sustaining an injury. Per director, child #1 had to seek medical treatment. LPA conducted interviews with the directors and staff members. Child #1 was not available to be interviewed during time of inspection. LPA reviewed records, obtained a copy of related documentation and facility roster. Based on the evidence obtained, it has been determined that staff #1 failed to provide adequate supervision to child #1 resulting in the child sustaining an injury. LPA and Director discussed playground supervision. Director states that a conference has been conducted with each staff member regarding playground supervision and the procedure required for children that are injured at the facility.

See LIC 809D for deficiency cited. AB 633 requires that a copy of this report be posted and provided to parents of all children currently enrolled and parents of newly enrolled children in the next 12 months. Signed receipt (LIC 9224) to be maintained in each child's record for future review by licensing staff. Form LIC 9224 was given to director.

Director was provided a copy of the Appeal Rights and their signature on this form acknowledges receipt of these rights. The NOTICE OF SITE VISIT (NOS) MUST BE POSTED FOR 30 DAYS. LPA observed the Nofice of Site Visit posted.

SUPERVISOR'S NAME: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2019

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. JOHN'S EVANGELICAL LUTHERAN CHURCH PRESCHOOL	FACILITY NUMBER: 376700649
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/06/2019 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). The requirement was not met as evidenced by: Director Tracy Davidson reported two unusual incident to the Dept. on 12/5/18 & 4/5/19.	1 2 3 4 5 6 7	Director provided LPA with a plan for playground supervision and the procedure required for children that are injured. The plan was discussed and signed by staff on 4/8/19. POC cleared during time of inspection.
	8 9 10 11 12 13 14	involving injuries to 2 children on each date that required medical attention. It was determined based on interviews conducted that adequate care and supervision was not provided to either child. This poses an immediate health and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Tulam Vu	TELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2019

LIC809 (FAS) - (06/04)

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