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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401701939
Report Date: 11/15/2019
Date Signed: 11/15/2019 11:38:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:PEACE CHRISTIAN PRESCHOOLFACILITY NUMBER:
401701939
ADMINISTRATOR:ANNETTE TAYLORFACILITY TYPE:
850
ADDRESS:244 OAK PARKTELEPHONE:
(805) 489-9644
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:92CENSUS: 35DATE:
11/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Annette TaylorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Melissa Stewart, made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPA met with facility Director Annette Taylor and discussed the purpose of the visit. There were 26 children supervised by three teachers outdoors and 9 children indoors with one teacher at the time of inspection. LPA met with Administrative Assistant who observed the incident which led to a child being injured while playing outdoors on 10/16/19 at approximately 4:35pm. The Administrative Assistant reported the incident to the Community Care Licensing Division (CCLD) office via phone on 10/17/19 and submitted a written Unusual Incident Report to the CCLD office on 10/23/19.

LPA observed the climbing structure where the incident occurred while the Administrative Assistant described the incident and noted that there were two teachers supervising 18 children at the time of the incident. The teachers were positioned on opposite sides of the outdoor activity area. The Administrative Assistant explained that she happened to be walking by at the time of the incident and observed C1 fall. As C1 stood up, C1 was covering C1s mouth and when C1 pulled C1s hands away, C1 observed the blood and began to cry. Teacher 1 provided comfort and first aid (cleaned the area and applied ice). Teacher 2 instructed the children to leave the climbing structure and cleaned and sanitized the area where the injury occurred. C1's father was contacted immediately. C1s mother arrived at 5:05pm and took C1 to the Emergency Room. C1 received 6 stitches. Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PEACE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 401701939
VISIT DATE: 11/15/2019
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C1 was seen by a dentist on 10/17/19 who confirmed that there was no injury to C1s permanent teeth. C1's parents decided to keep C1 home on Thursday and Friday (10/17/19 and 10/18/19). C1 returned back to school on Monday, 10/21/2019. There was no modified activity request (MAR) provided by the doctor. Director reported that since the incident, teachers have been talking with the children about playground safety and children have been advised to walk rather than run while on the structure.

LPA observed where the child had fallen. Given the Administrative Assistant's account of the incident when reporting it to CCL and how they addressed the incident, LPA deemed that all staff involved took appropriate action both at the time of the injury and after the injury.

No deficiencies were cited during today's visit.


LPA observed Notice of Site Visit posted.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
LIC809 (FAS) - (06/04)
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