370800634-4-12-2024-20-CC-VWIN-D49P8Y-20240412110620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370800634
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:06:25 AM

Document Has Been Signed on 04/12/2024 11:06 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
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	LA MESA UNITED METHODIST CHILDREN'S CENTER		FACILITY NUMBER:	370800634
ADMINISTRATOR/ DIRECTOR:	AMY FAGAN		FACILITY TYPE:	850
ADDRESS:	4690 PALM AVENUE		TELEPHONE:	(619) 466-8407
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY: 87	TOTAL ENROLLED CHILDREN: 82	CENSUS: 62	DATE:	04/12/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:21 AM
MET WITH:	Nancy Betancourt		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

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On 4/12/2024, at 9:21am., Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management inspection to follow up on a self reported incident. LPA met with teacher, Sarah Fredsti LPA discussed the purpose of the inspection and was led on a tour of the facility. There were 62 children present with ten (10) staff members.

On 4/9/2024, the director self- reported an incident regarding Child 1 (C1) sustaining an injury requiring medical attention. Per Director, the incident occurred on 4/8/2024 at about 10:45am.

Interviews were conducted with the director, assistant director, staff, C1 and C1's authorized representative. LPA inspected the playground and the slide attached to the play structure. LPA obtained photos of the playground, play structure and copies of facility sign in/sign out sheets for 4/8/2024.

Staff 1 (S1) reported that C1 was observed going down the slide and hugging the side of the slide as he was going. S1 stated that C1 flipped over the slide landing face first onto the padded surface beneath the play structure. S1 stated that she immediately went over to C1 to assess him for injuries and then took him inside of the facility. C1 was observed to have an abrasion to the left side of his face. Director, Amy Fagan cleaned the injury and applied ointment to his face. S1 stated that she was standing near the play structure, however she was not close enough to stop C1 from falling. S2 stated that she was on the other side of the play structure engaging with other children at the picnic table. Assistant Director stated that C1's authorized representative was contacted immediately after the incident. Per C1's authorized representative and documentation, C1 was seen by a medical professional. Per staff and sign in sheets there were 12 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: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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: 04/12/2024

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Based on LPA's observation and staff interviews it was determined that the play structure is age appropriate and there was staff supervision 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: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC809 (FAS) - (06/04)

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