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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701349
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:56:33 PM


Document Has Been Signed on 06/28/2022 03:56 PM - 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:MIRACLE MOMENTS CHRISTIAN PRESCHOOLFACILITY NUMBER:
376701349
ADMINISTRATOR:CYRCE MELLORFACILITY TYPE:
850
ADDRESS:2740 EAST FOURTH STREETTELEPHONE:
(619) 399-5463
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:25CENSUS: 9DATE:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Cyrce MellorTIME COMPLETED:
04:00 PM
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On 06/28/2022 at 2:50 PM, LPA Dana Stevens conducted an Unannounced Case Management visit for the purpose of follow-up on an Unusual Incident that occurred on 05/24/2022. Director accompanied LPA on a tour of the inside and outside of the facility.

On 05/24/2022 at around 1:00 PM, 3 teachers were supervising 10 children on the playground. Director stated that Child 1 (C1) was playing hide and seek with Staff 1(S1) and Child 2 (C2) asked C1 if he could join the game. C1 said "No" and bumped into C2 and C2 turned around and kicked C1 in the private parts. Director estimated that S1 was about 10-12 feet away from the children and witnessed the children fighting but was not able to intervene in time to prevent the incident. Staff immediately separated C1 and C2. C2 was given an ice pack and taken to the classroom. Parents of both children were immediately notified by phone. Staff provided both parents with "ouch reports" at pick up time which is around 1:30 PM.

LPA interviewed staff and inspected facility and playground. Further investigation is needed into this incident.

No deficiencies cited.

Notice of Site Visit must be posted for 30 days.
SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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