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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412388
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:24:29 PM


Document Has Been Signed on 04/06/2023 12:24 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
OAKLAND SOUTH EAST, 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: 32DATE:
04/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lysa MatichakTIME COMPLETED:
12:30 PM
NARRATIVE
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On April 6, 2023 at approximately 11:45am, Licensing Program Analyst (LPA) R. Haderer arrived unannounced to review the overdue lead testing requirements for the facility and issue a deficiency and plan of correction. Upon arrival there were 32 children and seven staff present, the facility was in ratio today.

LPA reviewed the lead testing requirements in detail, left all the documentation and issued the LIC809D deficiency and Plan of Correction.

Notice of site was provided and must remain publicly posted for 30 days.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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 2


Document Has Been Signed on 04/06/2023 12:24 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MONTESSORI SCHOOL OF CENTERVILLE
FACILITY NUMBER: 013412388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2023
Section Cited

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1597.16(a)(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023,
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Licensee will apply for the grant funding, contact a water sampling firm and initiate the testing to complete everything by May 15, 2023.
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and every five years after the date of the initial test.
Based on observation and interview, the
licensee did not meet the requirement of
completing lead testing which poses an 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: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2