<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191602269
Report Date: 03/18/2025
Date Signed: 03/18/2025 10:38:45 PM

Document Has Been Signed on 03/18/2025 10:38 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:ST. JOHN'S LUTHERAN CHURCH NURSERY SCHOOLFACILITY NUMBER:
191602269
ADMINISTRATOR/
DIRECTOR:		MARY JOSEPHINE MEADEFACILITY TYPE:
850
ADDRESS:1611 EAST SYCAMORETELEPHONE:
(310) 615-0211
CITY:EL SEGUNDOSTATE: CAZIP CODE:
90245
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 34DATE:
03/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Josephine MeadeTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On March 18, 2025, Licensing Program Analyst (LPA), V. Wheatley conducted a case management inspection and met with the director Josephine Meade. LPA observed 34 children in care being supervised properly by staff. The purpose of the inspection is regarding an incident whereby a 4 year old child was injured on 11/5/2024.

The child #1 was playing on the bike yard with Staff #1 and Child #2. The child #1 was playing with child #2 and according to Staff #1, the child #1 did a ninja-kick and fell on his elbow on the grass. Staff #1 states the child was able to move his arms and continued to play. Staff #1 left and went home. The child was supervised by Staff #2 who informed the parent at pick up time that the child was complaining about his arm. The child was taken to urgent care. The doctor's note states the child was seen for an orthopedic condition. The child came back to school with a cast. A doctor's note is required for the child to return back to school on 11/7/24. Per the director, the cast removed within a short amount of time. The doctor's note stated no athletic activities until 12/5/24.

The incident was telephoned to Community Care Licensing 11/6/24 by the director. The required LIC 624 Unusual Incident form was submitted to the Department within 7 days. Staff #1 submitted a declaration of what happened that day.

There are no deficiencies cited regarding this incident.

Exit interview conducted. A copy of the report was read and provided to the director.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1