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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070208839
Report Date: 11/13/2019
Date Signed: 11/13/2019 11:52:42 AM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:DIABLO VALLEY MONTESSORI SCHOOLFACILITY NUMBER:
070208839
ADMINISTRATOR:SUZETTE SMITHFACILITY TYPE:
850
ADDRESS:3390 DEERHILL ROADTELEPHONE:
(925) 283-6036
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:138CENSUS: 93DATE:
11/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Suzette SmithTIME COMPLETED:
11:55 AM
NARRATIVE
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LPA Dayna Collier met with Head of School Suzette Smith for a case management inspection as a result of receiving an unusual incident report. An incident occurred when the school celebrated Halloween which included an annual parade. Following the parade, parents were allowed to go into the classroom to take pictures. A group of children were signed out by their parents to leave for the day. One child walked along with a group of parents and children out to the parking lot. While the group was walking out, the staff member was in the classroom conducting a head count. The staff member proceeded to search for the child at the same time that one parent entered the gate to return the child back to the classroom. Although the child was with a group of parents and children, the child was not signed out to leave. Therefore, the facility was still responsible for providing supervision. The child was without a staff member's observation and/or supervision for about 5 minutes. Immediately following the incident, the child's parents were informed.

The attached type A deficiency is cited today and must be corrected by the due date. 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 Head of School.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: DIABLO VALLEY MONTESSORI SCHOOL
FACILITY NUMBER: 070208839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2019
Section Cited

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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This requirement was not met as evidenced by report review and interviews. This poses an immediate risk to children in care.
STAFF DID NOT OBSERVE A CHILD LEAVE THE CLASSROOM WITH A GROUP OF PARENTS.
AN LIC421IM FORM WAS GIVEN.
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A SUBSEQUENT VIOLATION OF LACK OF SUPERVISION WITHIN NEXT 12 MONTHS MAY RESULT IN AN IMMEDIATE $1,000 CIVIL PENALTY.

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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) 622-2593
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2019
LIC809 (FAS) - (06/04)
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