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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070211836
Report Date: 11/17/2020
Date Signed: 11/17/2020 11:14:50 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:FOUNTAINHEAD MONTESSORI SCHOOL ORINDA CAMPUSFACILITY NUMBER:
070211836
ADMINISTRATOR:NOELL WHITEFACILITY TYPE:
850
ADDRESS:30 SANTA MARIA WAYTELEPHONE:
(925) 254-7110
CITY:ORINDASTATE: CAZIP CODE:
94563
CAPACITY:129CENSUS: 32DATE:
11/17/2020
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Noell WhiteTIME COMPLETED:
09:35 AM
NARRATIVE
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LPA Dyer met with center director Noell White for a Case Management - Deficiencies inspection as a result of a complaint investigation. Due to Covid-19 and the shelter-in-place order, the visit was completed through FaceTime video platform. There were 32 children present.

On November 2, 2020 there was no power at the facility as a result of a planned Pacific Gas and Electric Public Safety Power Shutoff. Director failed to inform Community Care Licensing of the power outage and to submit an Unusual incident report.

The attached type B deficiency is cited and must be corrected by the due date. Exit interview conducted. Appeal rights were given.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) -28-4353
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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: FOUNTAINHEAD MONTESSORI SCHOOL ORINDA CAMPUS
FACILITY NUMBER: 070211836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2020
Section Cited

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Reporting Requirements.…A report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days (cont)
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following the occurrence of such event… Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement was not met as evidenced by report review. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in $100 civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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: Antranette RobinsonTELEPHONE: (510) -28-4353
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2020
LIC809 (FAS) - (06/04)
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