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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213903
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:05:53 PM


Document Has Been Signed on 02/24/2023 03:05 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MONTESSORI SCHOOL AT WASHINGTON AVENUEFACILITY NUMBER:
010213903
ADMINISTRATOR:YOUSSEF, MARIANFACILITY TYPE:
850
ADDRESS:14795 WASHINGTON AVENUETELEPHONE:
(510) 357-8432
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:111CENSUS: 65DATE:
02/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jungok "Rose" HwangTIME COMPLETED:
03:00 PM
NARRATIVE
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On 02/24/2023 at 10:45am, Licensing Program Analyst (LPA) Christina Uribe conducted an unannounced case management visit to the facility and met with facility representative, Jungok "Rose" Hwang. Also present at the time of the visit is 5 staff and 65 children.

During today's visit, LPA reviewed personnel records and conducted interviews with the staff which lead to the following deficiencies being issued today:
  • Type B Violation: 3 out of the 6 staff members present did not have a current Mandated Reporter certificate for Child Care Providers (AB 1207).
  • Type B Violation: An unusual incident took place on 02/15/23 involving a student choking on a single penny coin which caused the child to vomit. This incident was not reported to the licensing agency.

Please see attached deficiency pages for additional information. The licensee will correct these deficiencies based on the plan of correction on the LIC 809D form no later than the due date of 03/17/2023. Proof of correction will be emailed to LPA Uribe at christina.uribe@dss.ca.gov on or by the due date.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights were reviewed and given. Exit interview conducted and report was reviewed with the facility representative, Jungok "Rose" Hwang.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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Document Has Been Signed on 02/24/2023 03:05 PM - It Cannot Be Edited

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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: MONTESSORI SCHOOL AT WASHINGTON AVENUE
FACILITY NUMBER: 010213903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited

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Upon the occurence, during the operation of a child care center of any of the events specifiied in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. (1) Events reported shall include the following: (C)
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The licensee and all staff will visit the CCLD website at www.ccld.childcarevideos.org and watch the "Child Care Reporting Requirements" training video. The licensee will create a wrtitten statement acknowledging that they have watched the video, their responsibility to report incidents and a plan
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Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not met as evidenced by: The facility failed to report a recent unusual incident in which a child choked on a penny coin causing her to become distressed and vomit.
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of action for how incidents will be
reported in the future. Additionally, this statement will be signed and dated by all staff and the licensee. The licensee will email this completed and signed statement to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 03/17/2023.
Type B
03/17/2023
Section Cited

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(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete
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Licensee will ensure that these staff members will obtain a valid certificate by taking the Child Care Providers (AB 1207) training at www.mandatedreporterca.com. The licensee will email a copy of these certificaes to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 03/17/2023.
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renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by: 3 staff members do not have a current Mandated Reporter certificate.
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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