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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600029
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:34:39 PM

Document Has Been Signed on 08/23/2022 01:34 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ASCENSION LUTHERAN CHURCH DAY NURSERYFACILITY NUMBER:
191600029
ADMINISTRATOR:MAUREEN MORRISONFACILITY TYPE:
850
ADDRESS:26231 SILVER SPUR ROADTELEPHONE:
(310) 373-6083
CITY:ROLLING HILLSSTATE: CAZIP CODE:
90275
CAPACITY: 78TOTAL ENROLLED CHILDREN: 78CENSUS: 0DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jose Rodriguez, DirectorTIME COMPLETED:
02:00 PM
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On August 23, 2022 at 10:15 AM, Licensing Program Analyst (LPA) Miriam Cohen made an unannounced visit and met with Jose Rodriguez, Preschool Director, for the purpose of investigating regarding the Unusual Incident/Injury Report (UIR) that took place on 06/27/2022 at Ascension Lutheran Preschool located at 26231 Silver Spur Rd., Rancho Palos Verdes, CA 90275.

The UIR was reported on 06/27/2022 to the El Segundo Child Care Regional Office. Upon arrival, LPA observed no children in the day care. Per director, the preschool is on a two-day break for staff development. Fall semester will resume on 08/24/2022. During today’s inspection, preschool director and LPA Cohen toured the classroom where the incident occurred.

LPA obtained copies of the following: Ouch Report, and Emergency ID for the child involved.
Parent of the child was contacted and interviewed.
Based on the information that were gathered through record review, staff and parent interview, it revealed that on the day of the incident, the child was immediately assessed, epi pen administered, parent notified, and 911 called for urgent medical assistance. The child was taken by the local ambulance with child’s mother. The child return to the preschool on 06/29/2022 and remained enrolled in the preschool
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

An exit interview was conducted with Mr. Rodriguez. The notice of site visit must be posted for 30 days upon receipt.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Miriam Cohen
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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