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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 070210062
Report Date: 08/10/2022
Date Signed: 08/10/2022 10:36:34 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2022 and conducted by Evaluator Cherie Acosta
COMPLAINT CONTROL NUMBER: 02-CC-20220623081230
FACILITY NAME:FOUNTAINHEAD MONTESSORI SCHOOLFACILITY NUMBER:
070210062
ADMINISTRATOR:SAMAR SHAKALIAFACILITY TYPE:
850
ADDRESS:939 EL PINTADO ROADTELEPHONE:
(925) 820-6250
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:92CENSUS: 39DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Samar ShakaluaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Child sustained unexplained injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced visit to deliver findings on the above allegation.

It was reported that child received unexplained injury while in care. During the investigation LPA conducted multiple interviews. Although a child did have an injury LPA is unable to determine whether or not the injury happened while the child was in care at Fountainhead Montessori School.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

Notice of Site Visit was provided and must be posted for 30 days.
Exit interview and report reviewed with Samar Shakalua

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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