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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416606
Report Date: 12/08/2023
Date Signed: 12/08/2023 01:20:03 PM


Document Has Been Signed on 12/08/2023 01:20 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 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: 74DATE:
12/08/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Martha SanchezTIME COMPLETED:
10:30 AM
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On 12/08/2023 at 7:00am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with Director, Martha Sanchez, also present at the time of the inspection were 12 staff & 74 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. Solid waste bins are equipped with tight fitting lid.

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, toilets, and supplies.

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

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: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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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 AT FIVE CANYONS
FACILITY NUMBER: 013416606
VISIT DATE: 12/08/2023
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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 5 children’s files and 5 staff files. LPA reviewed the facility roster & personnel report and copies were obtained. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. Director was reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years. 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.

CCLD Inspection Process: 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.

Criminal Record Clearance: Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Lead Testing: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

MyChildCarePlan.org: Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
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 AT FIVE CANYONS
FACILITY NUMBER: 013416606
VISIT DATE: 12/08/2023
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Incidental Medical Services (IMS): This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. All children’s medications are securely stored, accompanied by their original packaging, and are in compliance with expiration dates. For IMS information see PIN 22-02-CCP. 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/resources/child-care-centers/.

Unusual Incident/Student Injury Report: 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.

See list below and attached pages for deficiencies and advisory notes issued today:

  • Type B Violation: Facility did not meet the reporting requirements for notifying CCLD of an outbreak of a communicable disease where there were two or more positive cases within a 14-day period.
  • Technical Violation: One staff member has a recently expired Child Care Provider certificate for Mandated Reporter training but does have an active General Training course.
  • Technical Violation: 3 prescription medications need an updated Parent Consent for Administration for Medication (LIC 9221) form.
  • Technical Violation: 2 non-prescription medications need an updated Parent Consent for Administration of Medication (LIC 9221) form.

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 given and reviewed. Exit interview conducted and report was reviewed with the director, 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: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 12/08/2023 01:20 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 AT FIVE CANYONS
FACILITY NUMBER: 013416606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101212(d)(1)(E)
101212 - Reporting Requirements: (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1), a report shall be made to the Department by telephone or fax within the Department's next working day and during normal business hours. In addition, a written report shall be subimitted to the Department within seven days following the occurrence of such event; (1) Events reported shall include; (E) Epidemic outbreaks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the facility did not report a recent event where two or more children were diagnosed with Hand, Foot, & Mouth Disease within a 14-day period which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Director will watch the "Child Care Reporting Requirements" at www.ccld.childcarevideos.org. Director will create a written statement explaining when and how an event should be reported to CCLD and email this written statement to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 01/08/2024 by 12:00pm
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8