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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412388
Report Date: 09/03/2021
Date Signed: 09/03/2021 03:03:49 PM

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 OF CENTERVILLEFACILITY NUMBER:
013412388
ADMINISTRATOR:MATICHAK, LYSAFACILITY TYPE:
850
ADDRESS:4209 BAINE AVENUETELEPHONE:
(510) 797-9944
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:85CENSUS: 27DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH:Lysa MatichakTIME COMPLETED:
03:15 PM
NARRATIVE
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On September 3, 2021 at approximately 7:56am Licensing Program Analyst (LPA) Russ Haderer arrived to conduct an unannounced random annual site inspection for this pre-school facility. LPA met with Site Director Lysa Matichak and toured all licensed areas used by children in care for a health and safety inspection. Also present today were 6 additional staff preparing classrooms for opening. Due to the early start, there were no children present when LPA arrived. However, during inspection the inspection process 27 children arrived. All adults present are background cleared and associated to this facility.

There are 2 buildings containing administration offices, 4 classrooms, a kitchen and outside playground areas. All play equipment is in safe condition and free from sharp, loose or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Shade was available in the play areas and teachers will always be present.

The facility has a fully charged 2A10BC fire extinguishers in each building, the last annual inspection was done in Feb 9, 2021. There are working carbon monoxide detectors (tested and working). Heating and ventilation is acceptable.

The school provides breakfast, hot lunches, afternoon snacks and water is available for the children, menus are posted. Children also bring their own bottles for water. Food stocks in the kitchen were checked (frozen and refrigerated foods were also checked). There were some expired snack items in the cupboards.

There is an outside drinking fountain that is not in use at this time. The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. There were no hazardous items/toxins observed to be accessible to children in care today. There are no bodies of water accessible to children in care.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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 6
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 OF CENTERVILLE
FACILITY NUMBER: 013412388
VISIT DATE: 09/03/2021
NARRATIVE
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Napping cots are available for children that need to sleep and items for sleeping are labeled with their names in cubbies. All classrooms have cubbies for children’s personal belongings (including the bedding for napping cots), personal items do not come into contact with other personal items.

Earthquake and fire drills are conducted monthly. The last drills were conducted on July 15, 2021. There are ample children’s bathroom with toilets, sinks and appropriate hand washing signage. There are enough towels and soap supplies. All toilets, hand washing and cleaning areas are in safe and sanitary operating condition.

The school uses manual sign in/out sheets with clean pen bins and used pen bins. The sign-in/sign-out notebooks are on a table near the entrance gate. It was found that 4 children present had not been signed in. Covid protocol is followed (temperatures measured, hand washing (or sanitizer used) upon entry, all children and staff wear face coverings whenever indoors. All classrooms have windows and good cross ventilation.

The facility has children that require incidental medication (EpiPen’s and anti-histamines for allergies). It was found that medications had expired. Site director immediately contacted the parents to pick up the expired meds and provide unexpired product by next school day.

At approximately 11:40am LPA performed children's record reviewed: LPA requested and reviewed facility roster. All files selected were complete and up to date.

At approximately 12:00pm LPA performed staff file review. All staff subjected to criminal review have been cleared and associated to the facility. All files were complete, CPR and 1st Aid training is due for the staff, it is scheduled for October 17, 2021. All files were found to be in compliance with Title 22 regulations.

Site Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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 OF CENTERVILLE
FACILITY NUMBER: 013412388
VISIT DATE: 09/03/2021
NARRATIVE
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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

There were deficiencies cited today, see LIC809-D for details. A copy of this report to remain on file for 3 years.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Lysa Matichak.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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 OF CENTERVILLE
FACILITY NUMBER: 013412388
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited

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101229.1 Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.
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Based on observation and interview, the
licensee did not meet the requirement since parents of four children in the center had not signed in their children which poses a potential Health and Safety 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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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 OF CENTERVILLE
FACILITY NUMBER: 013412388
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited

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101227 Food Services
(a) In child care centers providing meals to children, the following shall apply:
(8) … All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption….
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Based on observation and interview, the
licensee did not meet the requirement as there were recently expired crackers and snacks which poses a potential Health and Safety 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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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 OF CENTERVILLE
FACILITY NUMBER: 013412388
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited

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1596.808 Beverages served by day care providers to children....
(a) Commencing January 1, 2012, except as provided in subdivisions (b) and (c), ....(1) Whenever milk is served, serve only lowfat (1 percent) milk or nonfat milk to children two years of age or older.
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Based on observation and interview, the
licensee did not meet the requirement since LPA observed 2 and a helf gallons of 2% milk in the refridgerator for the children to drink which poses a potential Health and Safety 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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6