Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619869
Report Date: 11/14/2016
Date Signed 11/14/2016 02:25:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MONTESSORI HOUSE OF CHILDRENFACILITY NUMBER:
293619869
ADMINISTRATOR:PETTY, SUSANNAFACILITY TYPE:
850
ADDRESS:12509 BURMA RDTELEPHONE:
(530) 274-7938
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95959
CAPACITY:24CENSUS: 17DATE:
11/14/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Emily NorlandTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amie Randa met with Director Susanna Petty for an unannounced annual inspection. Today’s census was 17 children and three staff members, who have all been finger-print cleared through Community Care Licensing. LPA toured the facility including all activity/classroom areas, food service area and restrooms. LPA observed that furniture and equipment are in good condition, the food preparation area is kept clean and sanitized and the restrooms are safe and sanitary. The Director stated that the facility provided morning/afternoon snack and and the parents provide lunch; LPA observed a current menu posted in on the parent board.

LPA observed that at least one staff member present during today’s inspection has a current Pediatric CPR/First Aid that expires on 06/2017. LPA observed that poisons are locked, cleaning compounds are inaccessible to children and the Director stated there are no firearms or bodies of water on the property. LPA reviewed care and supervision of children and staffing ratios, there is one teacher for every 12 children in care; however they had a child napping alone in a classroom without a teacher present or visual supervision. LPA observed that medications are centrally stored and inaccessible to children. LPA reviewed children’s files and observed that each child had their Identification/Emergency Information and the Consent for Medical Treatment form filled out and signed by their authorized representative. LPA also reviewed staff's educational background /transcripts, and none of the staff had their transcripts in their files; therefore LPA could not verify if the staff is qualified. LPA observed that outdoor activity space surfaces are free of hazards, playground equipment is in safe condition and drinking water is made readily available to children both indoors and outdoors.

LPA provided the Community Care Licensing’s website (www.ccld.ca.gov), so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised the licensee of their responsibility to stay current in regards to new regulations. Report continued on 809 C.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2016
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MONTESSORI HOUSE OF CHILDREN
FACILITY NUMBER: 293619869
VISIT DATE: 11/14/2016
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LPA discussed Departments inspection authority regulations with the Director and informed her that if any changes occur regarding the Designee/Director or an employee acting in their absence must be reported to Department within 10 working days. When LPA arrived the Director was not present and she learned that the Director is usually not present in the afternoon, the person listed as the designee on the LIC 308 is no longer employed at the facility; therefore the LIC 308 needs to be updated. LPA advised the Director that she needs to be present in the afternoon or have a designee that meets the requirements to act as the director in her absence.

LPA also discussed Unusual Incident Reports (UIRs) and reporting requirements. LPA informed the Director that if any unusual incidents occur she must contact the Department within 24 hours and an UIR must be submitted with 7 day, describing the specifics to the incident.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

In the areas that were evaluated, 3 deficiencies were cited during the visit.

Title 22 Deficiencies have been cited on the attached LIC 809 D. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809 D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809 D in each child's file.

LPA read this report to the employee, she stated that she acknowledges and understands today's inspection. LPA provided appeal rights provided and observed the posting of the Notice of Site Visit.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2016
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MONTESSORI HOUSE OF CHILDREN
FACILITY NUMBER: 293619869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2016
Section Cited
101212(b)
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Reporting Requirements. The name of the child care center director or fully qualified teacher(s) designated to act in the director’s absence shall be reported to the Department with in 10 days of a change. LPA learned that the Director is usually not present in the afternoon and the person listed as the designee on the LIC 308
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POC: The Director stated she will have one of her staff members act as the Director in the afternoon. LPA provided a Director checklist that indicates what needs to be submitted for the acting Director. Director stated she will submit the packet to LPA Randa by 12/14/2016
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is no longer employed. LPA met with a different employee and advised the employee that the facility need a fully-quilifed Director present 80% of the time.
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Type B
11/14/2016
Section Cited
101212(a)(1)(A)
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Reporting Requirements Verification of the completion of the course work required in Section 101215.1(h). A photocopy of a college transcript, or a photocopy of a Child Development Site Supervisor Permit or a Child Development program Director Permit, shall meet this requirement. LPA did not observe that
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POC: Director stated that all the staff is fully-quiliied and she will have them all print their transcripts and put them in their files. Director stated she will send LPA Randa all the transcripts by 12/14/2016.
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any of the staff had their transcripts in their files. Director stated all the staff are fully-quilified; however she overlooked printing the transcripts.
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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: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2016
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MONTESSORI HOUSE OF CHILDREN
FACILITY NUMBER: 293619869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2016
Section Cited
101229(a)(1)
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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time. When LPA arrived to the facility it was nap time. Two teacher were in one classroom with 13 children, one teacher was in the nap room with three children and one child was alone in another
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POC: Citation was cleared during inspection when a staff member moved the child to the nap room with the other children. The Director stated going forward they'll have the child nap with all of the other children in the nap room.
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classroom without visual supervision, which is an immediate risk to children in care.
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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: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2016
LIC809 (FAS) - (06/04)
Page: 4 of 4