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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566208209
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:55:39 AM


Document Has Been Signed on 04/10/2024 10:55 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:GRACE BRETHREN PRESCHOOL EASTFACILITY NUMBER:
566208209
ADMINISTRATOR:JULIA CHANDLERFACILITY TYPE:
850
ADDRESS:2762 AVENIDA SIMITELEPHONE:
(805) 582-4270
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:136CENSUS: 76DATE:
04/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dawn MudenTIME COMPLETED:
11:15 AM
NARRATIVE
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On 4/10/2024 at 9;00, Licensing Program Analyst (LPA) Veronica Diaz conducted a Case management incident inspection at the Child Care Center (CCC), for the purpose of following up on the report of an Unusual Incident Report (UIR) received by the Department on 3/25/2024. Specifically, the incident involved a child in care, C1, was left unattended in the restroom. LPA met with Director Dawn Munden discuss the purpose of today's inspection. LPA notes 5 children and 1 staff were present during time of incident.

Director Dawn Munden informed Licensing, C1 was left behind in bathroom. Staff counted students and made their way back to the classroom. Staff 1 seen C1 parent and asked Staff 2 where was C1, Staff 1 realized that C1 was not in either classroom, Staff 1 returned to the bathroom where C1 was located still inside. C1 has no prolonged effects related to the incident. Director contacted parent aboyt the incident that occurred. Parent reported that C1 will stay home for at least one day. C1 continues to be enrolled in the facility and parents have not expressed terminating services.

LPA and Director discussed active supervision. Director reported CCC has conducted investigation and made proper updates to ensure this incident does not occur again. The circumstances were investigated by the administrator to determine what factors contributed to the incident and steps to prevent it from happening again are in place. The expectations regarding safety and supervision are and will continue to be strongly communicated to our staff through training and meetings. Staff 1 has received a written documentation of corrections and it will be recorded in her personnel file.

CONT 809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Veronica DiazTELEPHONE: (805) 562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GRACE BRETHREN PRESCHOOL EAST
FACILITY NUMBER: 566208209
VISIT DATE: 04/10/2024
NARRATIVE
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LPA investigated this incident and based interview with staff, P1, record reviews and LPA personal observation there is sufficient evidence in lack of supervision to support that resulted in C1 being left in the bathroom. Therefore, the following deficiencies will be sited today

101229 (a) (1) Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the children's needs.


(1) No child(ren) shall be left without the supervision of a teacher at any time,

Following the incident C1 continues to be enrolled in the CCC.



During today’s inspection type B deficiencies was provided regarding Lack of supervision .

Exit interview and review of report was conducted with Director Dawn Munden Notice of Site visit was provided and must remain posted for the next 30 days.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Veronica DiazTELEPHONE: (805) 562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/10/2024 10:55 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117


FACILITY NAME: GRACE BRETHREN PRESCHOOL EAST
FACILITY NUMBER: 566208209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time,
This requirements is not met as evidence by:
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Assistant Director leading, training and supervising Teacher.
Disciplinary Action was given to Teacher
Training once a month staff meeting and staff development days.
3 checks system with name to face, name to verbal response, highlight name and number.
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Based on reporting and interview the licensee did not comply with the section cited above in which poses/posed a potential health, safety, or personal rights risk to persons in care.
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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: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Veronica DiazTELEPHONE: (805) 562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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