Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619869
Report Date: 05/15/2018
Date Signed 05/15/2018 12:06:27 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: 22DATE:
05/15/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susanna PettyTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Keven Peters met with the director for an Annual/Random inspection. LPA toured the facility, including all activity/classroom areas.

LPA observed that hazardous items (disinfectants, cleaning solutions etc.) were inaccessible to children in care. LPA reviewed care and supervision of children, staffing ratios, health related services, including medications and first aid supplies, furniture, equipment, fire drills, drinking water. LPA observed sinks, and toilets are operable.
Today’s census was 22 preschool age children with 3 staff in separate rooms.

LPA observed all required forms to be posted. First aid supplies were available. There are adequate toys and equipment & supplies available for children.

LPA reviewed the sign/in-sign/out sheets. LPA reviewed children’s & staff files. All staff currently employed with the facility has criminal record clearances and health screening reports with TB test. At least one staff member present today has current Pediatric CPR and First Aid, however LPA did not observe EMSA stickers or on any of the certifications.

Outdoor play area: LPA observed equipment appeared in safe condition, with adequate cushioning material. LPA observed drinking water and shade available.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2018
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 3
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: 05/15/2018
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed recent changes in licensing requirements, including SB 277 and SB 792 pertaining to immunization requirements for children and staff. LPA reviewed staff files and observed staff immunization records. AB 1207 Mandated Reporting Training was also discussed.

LPA provided the Licensing Agency website (www.ccld.ca.gov), so the licensee may obtain updated licensing information, regulations, and forms.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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

Deficiencies were documented on the 809-D



Report was reviewed with the director, exit interview was conducted.

Notice of Site Visit posted.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2018
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 05/15/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2018
Section Cited
CCR
101216(f)
1
2
3
4
5
6
7
Personnel Requirements. At least one person trained in CPR and Pediatric first aid shall be present when children are at the facility or offsite activities. LPA observed current CPR/First Aid Certificates in staff files however LPA did not observe EMSA stickers on the certifications.
1
2
3
4
5
6
7
The director stated she believes the certificates are EMSA certified. She states she will contact the company to confirm the certification. She will either provide proof of EMSA or enroll in approved CPR/ First Aide courses by the due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2018
LIC809 (FAS) - (06/04)
Page: 3 of 3