Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619869
Report Date: 05/15/2018
Date Signed 05/15/2018 12:05:09 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susanna PetterTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Keven Peters met with the director for a case management visit on this date to discuss the unusual incident report (UIR) that the facility submitted on 05/07/2018 via mail. During today's visit the facility was toured, todays census was 22 preschool age children with 3 staff.

In the UIR, a 3-year-old child fell while playing on the play structure. The child lost their balance while climbing the structure. The child fell on their right arm. Staff states that the child was able to move their arm and wiggle their fingers. The child continued to cry, the parents were notified. The child was taken to the doctor where they were diagnosed with an arm fracture.

LPA's observed areas where the child was playing when they fell. The play structure appeared to be structurally sound, and there appeared to be adequate resilient material under the structure.

After interviews with staff and observing the area, LPA determined that no Title 22 violations took place.

Report was reviewed with the director, exit interview conducted.

Notice of Site Visit to be 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
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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