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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 070211836
Report Date: 05/25/2022
Date Signed: 06/08/2022 12:53:46 PM

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
05/18/2022 and conducted by Evaluator Ashley Curry
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20220518090802
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: 43DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Noell WhiteTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is not properly reporting COVID-19 outbreak as required
INVESTIGATION FINDINGS:
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On 05/25/2022 at 10:00 AM Licensing Program Analyst (LPA) A. Curry conducted an unannounced complaint investigation. LPA met with the director Noell White to discuss the above allegation. There were 43 children present today. The allegation is the facility is not properly reporting COVID-19 outbreak as required. The LPA conducted interviews and reviewed facility records. Although Licensing only received two faxes, at a later time the director was able to provide confirmation of faxed LIC 624 forms that were sent to the office for each COVID case. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. This allegation is Unsubstantiated.

The director is reminded to report any injuries or unusual incidents, including COVID-19 exposures, positive results at the facility, and hand, foot, and mouth disease. All individuals on the LIC 624 Unusual Incident/Injury Report form must be addressed by first and last name, including staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 02-CC-20220518090802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/25/2022
NARRATIVE
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This is an amended report due to additional information received.

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.

An exit interview was conducted with facility representative Noell White, appeal rights were given, and a copy of this report was provided to the director.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 02-CC-20220518090802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
CCR
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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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3