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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290357
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:42:46 PM

Document Has Been Signed on 06/28/2023 01:42 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GRANDVIEW PRESBYTERIAN CHURCH COMM CHILDRENS CTR.FACILITY NUMBER:
191290357
ADMINISTRATOR:MULLICH, ROXANNEFACILITY TYPE:
850
ADDRESS:1130 RUBERTA AVETELEPHONE:
(818) 243-1088
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 68TOTAL ENROLLED CHILDREN: 68CENSUS: 32DATE:
06/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Roxanne Mullich, DirectorTIME COMPLETED:
02:00 PM
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On June 28, 2023, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Case Management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. The purpose of the inspection is follow up on an incident that occurred on 06/23/2023; the incident was reported to the department in a timely manner. LPA observed 32 children in care.

Brief Summary: On 06/23/2023 at approx 11:30AM, Child #1 (C1) was playing/swinging on the tire swing when the child's friends were pushing C1 on tire swing. C1 was holding onto the chains of the tire swing when another friend spun C1 in circles. C1's left index finger was caught in the chain, she tried to pull her finger out and bent her finger. Staff #1 saw S2 and asked her to call the director. Staff #3 called C1's parents and C1 was taken to urgent care and from there was sent to the emergency room. As a result of the incident C1 has a broken and displaced finger.

During this inspection LPA interviewed S1, C1, obtained a copy of the facility roster, obtained a copy of sign in sheet for children and staff that were in attendance the day of the incident (ladybug classroom) and took photographs of the tire swing.

Based on interviews with S1 and C1, C1 stated she was playing on the tire swing when 2 friends were pushing her on the swing. Per C1, the tire swing started to spin and her finger was stuck in the chain. Per S1, she observed the tire swinging and walked over to the swing when she observed C1's finger was stuck in the chain. Per S1, she was untangling the tire/chain to assist C1 in removing her finger from the chain. Per S1 and C1, C1 pulled her finger out of the chain. S1 stated that once C1 has removed her finer from the chain, C1's finger did not look normal. S1, stated she applied ice on C1's finger. Per C1, S1 was standing about 20 feet near the tire swing area. LPA reviewed Ladybug classroom sign in where only 11 children were present on the day of the incident.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRANDVIEW PRESBYTERIAN CHURCH COMM CHILDRENS CTR.
FACILITY NUMBER: 191290357
VISIT DATE: 06/28/2023
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Per S1 and C1, S1 was the only staff member outside as the classroom assistant S3 was on break. S1, stated that she felt there was enough supervision at the time of the incident. Per C1, she was taken to the hospital and now has a cast on her left hand/arm along with a splint on her finger. Per director, C1 returned to the facility on 06/26/2023.

There are no deficiencies being cited as this was an incident that occurred fast and was unable to be prevented. Per S1 she witnessed the incident occur and took the proper measures to ensure C1 received the proper first aid care.

An exit interview was conducted and a copy of this report along with Notice of Site Visit was provided to director.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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