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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416606
Report Date: 12/15/2022
Date Signed: 12/15/2022 03:56:54 PM


Document Has Been Signed on 12/15/2022 03:56 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 FIVE CANYONSFACILITY NUMBER:
013416606
ADMINISTRATOR:VAN GROENOU, MEHERFACILITY TYPE:
850
ADDRESS:22781 CANYON COURTTELEPHONE:
(510) 581-3729
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY:120CENSUS: 73DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Martha SanchezTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/15/2022 at 9:00am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with Assistant Director, Martha Sanchez, also present at the time of the inspection were 10 staff & 73 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 7:00am-6:00pm, Monday-Friday in 5 classrooms (Rose, Lily, Tulip, Marigold, & Sunflower classrooms).

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 2A10BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available to children.

Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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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 FIVE CANYONS
FACILITY NUMBER: 013416606
VISIT DATE: 12/15/2022
NARRATIVE
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Records: LPA reviewed 5 children’s files and 5 staff files. LPA reviewed the facility roster & personnel report. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. The center's sign in and out forms were reviewed. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

Health-Related Services: This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 101226. 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Facility representative 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.

Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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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 FIVE CANYONS
FACILITY NUMBER: 013416606
VISIT DATE: 12/15/2022
NARRATIVE
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Please see list below and attached pages for deficiencies and advisory notes cited during today's inspection:
  • Type B Violation: 6 medications were found to be stored without their original packaging.
  • Type B Violation: 3 medications were found to be missing a Parent Consent for Medication Administration (LIC 9221) form.
  • Type B Violation: Several staff members were either missing proof of immunization for Measles (MMR), Pertussis (Tdap), or both.
  • Type B Violation: Two staff members have an eligible criminal background clearance and both have a current "Active-Working" status, however, neither of them were associated to the facility.
  • Technical Violation: Several staff members need to renew their expired Mandated Reporter certification for Child Care Providers (AB 1207).
  • Technical Violation: Updated TB clearance and Health Screening Report (LIC 503) form needed for two staff members.
  • Technical Violation: One child's Identification & Emergency (LIC 700) form needs an updated information for physician or dentist to be called in an emergency.
  • Technical Violation: Sign in and out forms were not in compliance as several children were missing either signatures and/or times for in or out over several days.

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. Exit interview conducted and report was reviewed with the facility representative, Martha Sanchez..

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 12/15/2022 03:56 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 FIVE CANYONS
FACILITY NUMBER: 013416606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(1)(B)
Health-Related Services
(e) In centers where the licensee chooses to handle medications: (1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (B) Each container shall have an unaltered label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 6 medications were found to be stored without their original container/packaging which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Facility will ensure that all medicatiosn with missing containers have their original packaging or replaced. Director will email proof of correction for each child's missing containers to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 01/16/23.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above as several staff members are missing proof of immunization for Measles (MMR), Pertussis (Tdap) or both which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Staff members will obtain proof of immunization for Measles (MMR) & Pertussis (Tdap). Director will email proof of these records to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 01/16/23.
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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 12/15/2022 03:56 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 FIVE CANYONS
FACILITY NUMBER: 013416606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above as two staff members did have an elibigle clearance and an "Active-Working" status but did not have their criminal record clearance associated to the faciltiy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Both staff members were associated to the facility during today's inspection and the deficiencies has been corrected.
Type B
Section Cited
CCR
101226(e)(3)(B)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 medications did not have a signed Parent Consent for Administration of Medication (LIC 9221) form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Facility will ensure that all medications have a complete and separate Parent Consent for Administration of Medication (LIC 9221) form with each medication. DIrector will email proof of these signed records to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 01/16/23.
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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9