Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420906
Report Date: 01/14/2019
Date Signed 01/14/2019 09:48:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LITTLE FLOWERS MONTESSORIFACILITY NUMBER:
013420906
ADMINISTRATOR:MAHAJAN, GAURIFACILITY TYPE:
850
ADDRESS:4343 STEVENSON BLVDTELEPHONE:
(510) 651-2605
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:100CENSUS: 44DATE:
01/14/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gauri MahajanTIME COMPLETED:
09:55 AM
NARRATIVE
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LPA Dayna Collier met with Center Director Gauri Mahajan for a case management inspection. During the inspection, the Director revealed that an unusual incident occurred but had not been reported to the Department as required.

The attached type B deficiency is cited today and must be corrected by the due date. This report must be available for public review for 3 years. An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted by the Director.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2019
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: LITTLE FLOWERS MONTESSORI
FACILITY NUMBER: 013420906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2019
Section Cited
CCR
101212(d)
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101212(d) Reporting Requirements. A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified.
This requirement was not met as evidenced by the director's admission during today's inspection. This poses a potential risk to the health and safety of children in care.
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POC: By 1/21/19, a written unusual incident report will be submitted to Licensing detailing the incident involving a child in care.
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The director failed to report an unusual incident to Licensing.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2019
LIC809 (FAS) - (06/04)
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