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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412619
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:49:10 PM


Document Has Been Signed on 11/15/2023 03:49 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MONTESSORI CHILDREN'S CENTERFACILITY NUMBER:
013412619
ADMINISTRATOR:SALVADOR, LULETTEFACILITY TYPE:
830
ADDRESS:33170 LAKE MEAD DRIVETELEPHONE:
(510) 489-7510
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:20CENSUS: 13DATE:
11/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lulette SalvadorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 11/15/2023 at 2:00PM Licensing Program Analyst (LPA) Jaleesa Jackson met with Director Lulette Salvador for an Unannounced Case Management Visit for a unusual incident report that was received on 10/27/2023.Present at the facility were 5 finger print cleared staff and 13 infants in care.

On 10/25/2023 a parent observed a teacher (S1) violating a child's personal rights and recorded the incident then showed the director the following day on 10/26/2023.

On 10/25/2023, S1 was supervising 3 children (C1 included). A parent witnessed and recorded S1 pushing C1. C1 then fell to the ground. The next day the parent showed the video of the incident to the Director. The Director then had a meeting with S1 about the incident. The incident was then brought up to the management and then the decision was made to terminate S1 from the facility. The Director stated the next day all staff were brought in individually and given a copy of the Personal Rights form (LIC613A). The Director went over with each staff member what the child's personal rights are.

There was 1 deficiency cited on today's visit. See 809-D for deficiency. Appeal rights were given to Director.

LPA Jackson informed licensee facility representative Lulette Salvador that this report dated 11/15/2023 document 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Jackson informed the facility representative to provide a copy of this licensing report dated (insert visit date) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Notice of site visit was given and exit interview was conducted with Director Lulette Salvador.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Jaleesa JacksonTELEPHONE: (510) 368-0021
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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 11/15/2023 03:49 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MONTESSORI CHILDREN'S CENTER
FACILITY NUMBER: 013412619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2023
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights (a)(3) The licensee shall ensure that each child is accorded the following personal rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule... or other actions of a punitive nature including but not limited to...
This requirement was not met as evidenced by:
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Director let S1 go immediately after the incident was brought to her and managements attention. The director has gone over personal rights with all staff. Deficiency has been cleared.
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Based on interview, S1 has violated C1's personal rights which posed an immediate risk to the health and safety of 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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Jaleesa JacksonTELEPHONE: (510) 368-0021
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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