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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418096
Report Date: 02/12/2020
Date Signed: 02/12/2020 02:35:34 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:CHILDREN'S MONTESSORI ADVENTUREFACILITY NUMBER:
013418096
ADMINISTRATOR:LORENA R. ALEJANDREFACILITY TYPE:
850
ADDRESS:580 JOAQUIN AVE.TELEPHONE:
(510) 352-4341
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:36CENSUS: 29DATE:
02/12/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Ruth Lopez / Lorena AlejandreTIME COMPLETED:
02:40 PM
NARRATIVE
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LPA Dayna Collier met with Teacher Ruth Lopez for a case management inspection as a result of receiving an unusual incident report. During the inspection, Center Director Lorena Alejandre arrived. An incident occurred when a child had an allergic reaction as a result of consuming almond creamer. Per staff, oatmeal was served for breakfast to the children. When the staff member thought the facility ran out of milk, the staff member began to serve another staff member's almond milk coffee creamer to the children. Although staff are aware that one child had a nut allergy, the child was offered the almond milk coffee creamer. Once on the playground, the child began to show signs of having an allergic reaction. The child's parent was contacted and 911 was called. The child was transported to the hospital via ambulance. Per staff, the facility has now become a nut-free environment for staff as well as children.

The attached type A and B deficiencies are cited today and must be corrected by the due dates. Upon receipt, licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted by the Director.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
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 3
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: CHILDREN'S MONTESSORI ADVENTURE
FACILITY NUMBER: 013418096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2020
Section Cited

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met and poses an immediate risk to children in care.
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A STAFF MEMBER OFFERED A CHILD ALMOND MILK CREAMER WHICH HE CONSUMED AND RESULTED IN AN ALLERGIC REACTION.
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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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: CHILDREN'S MONTESSORI ADVENTURE
FACILITY NUMBER: 013418096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2020
Section Cited

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101227 Food Services
(a) In child care centers providing meals to children, the following shall apply:
(6) Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the
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menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.
This requirement was not met and poses a potential risk.
BREAKFAST MENUS ARE NOT POSTED.
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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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3