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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800634
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:57:41 PM

Document Has Been Signed on 09/04/2024 02:57 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:		NANCY BETANCOURTFACILITY TYPE:
850
ADDRESS:4690 PALM AVENUETELEPHONE:
(619) 466-8407
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 87TOTAL ENROLLED CHILDREN: 56CENSUS: 44DATE:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:Nancy BetancourtTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 9/4/2024, at 12:46pm., Licensing Program Analysts (LPAs) Vicky Williamson and Angela Nguyen conducted an unannounced case management inspection to follow up on a self reported incident. LPA met with Interim Director, Nancy Betancourt. LPA discussed the purpose of the inspection and was led on a tour of the facility. There were 44 children present with 10 staff members.

On 8/16/2024, the Interim Director self- reported an incident regarding Child 1 (C1) slipping on the ladder of a play structure. Per Interim Director, the incident occurred on 8/16/2024 at about 11:19am.

Interviews were conducted with the interim director and staff. LPA inspected the playground and the ladder attached to the play structure. LPA obtained photos of the playground, play structure and copies of facility sign in/sign out sheets for 8/16/2024.

Staff 1 (S1) reported that C1 was observed climbing onto the ladder part of the play structure when he slipped on the last loop of the ladder. C1 bumped his head on the structure as he fell down landing on the padded cushioning around the play structure. C1 was immediately by S1 and first aid applied to the injury. Per Staff 1 and Staff 2, no visible injuries were present. Per Interim Director, C1’s authorized representative arrived to the facility shortly after the incident and was notified upon arrival. Per staff and sign in sheets there were two (2) staff, and five (5) children present on the playground during the time of the incident.

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 Interim 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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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