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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800634
Report Date: 04/08/2024
Date Signed: 04/08/2024 03:14:25 PM

Document Has Been Signed on 04/08/2024 03:14 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:LA MESA UNITED METHODIST CHILDREN'S CENTERFACILITY NUMBER:
370800634
ADMINISTRATOR/
DIRECTOR:		AMY FAGANFACILITY TYPE:
850
ADDRESS:4690 PALM AVENUETELEPHONE:
(619) 466-8407
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 87TOTAL ENROLLED CHILDREN: 82CENSUS: 54DATE:
04/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:Nancy BetancourtTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 4/8/2024, at 2:16pm., Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection regarding a self reported incident. LPA met with Assistant Director, Nancy Betancourt. LPA discussed the purpose of the inspection and was led on a tour of the facility. There were 54 napping children present with five (5) staff members.

On 2/27/2024, the director self- reported an incident regarding Child 1 (C1) sustaining an injury requiring medical attention. Per Director, the alleged incident occurred on 2/26/2024 at about 10:20am.

Interviews were conducted with the director, assistant director, staff and C1's authorized representative. LPA was unable to interview C1, C2 and C3. LPA conducted a tour of the playground and inspected the plastic Little Tikes basketball goal. LPA observed a plastic Little Tikes basketball goal without the net attached to the rim. LPA obtained photos, facility sign in/sign out sheets, and reviewed the manufacturer's manual for the Little Tikes basketball.


Staff 1 (S1) reported that C1 was observed on the playground playing with a plastic Little Tikes basketball goal. S1 stated that she observed C1 standing on the base of the goal pushing the backboard forward. Per S1 she advised C1 that his actions were not safe and he stepped down. S1 stated that she turned to assist Child 2 (C2) who was on the slide located on the playground attached to the play structure when she heard C1 crying. Staff 2 (S2) who was closer to the area where C1 was located went to assist C1. S2 stated that she was assisting C3 on the ladder located on the play structure. S1 and S2 acknowledged that they did not witness the fall due to assisting other children on the playground; however both staff observed C1 on the ground with the basketball goal in a sitting position. S2 assessed the injury and S1 applied first aid immediately. S1 contacted Assistant Director, Nancy Betancourt and C1's authorized representative was contacted. Per staff, C1's authorized representative and documentation the injury required medical attention. S1 and S2 stated that they were supervising 18 children on the playground during the time of the incident. See LIC 809C Continuation...
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: LA MESA UNITED METHODIST CHILDREN'S CENTER
FACILITY NUMBER: 370800634
VISIT DATE: 04/08/2024
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Assistant Director and S1 stated that the Little Tikes basketball goal was removed from the playground immediately. Based on staff interviews and a review of the manufactures manual, it was determined that the Little Tikes basketball goal is age appropriate and there was supervision provided on the playground. The incident is determined to be an accident.

No deficiencies cited. Exit interview was conducted with Assistant Director, Nancy Betancourt and a copy of this report and Appeal Rights were provided. A notice of site visit was given and must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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