073405005-5-22-2019-02-CC-ARON-BFQSJF-20190905135455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073405005
Report Date: 05/22/2019
Date Signed: 05/22/2019 04:09:09 PM

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
05/06/2019 and conducted by Evaluator Geneen Redmond

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20190506141751

FACILITY NAME:	A LITTLE WORLD MONTESSORI ACADEMY		FACILITY NUMBER:	073405005
ADMINISTRATOR:	SAMUDRA DE ALWIS		FACILITY TYPE:	850
ADDRESS:	355 PARKER AVE		TELEPHONE:	(510) 799-6361
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	34	CENSUS: 14	DATE:	05/22/2019
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Samudra De Alwis, Director		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff hit day-care children - Personal Rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Redmond conducted an unannounced, Complaint Investigation visit on this date, regarding the above listed allegation. LPA met with Samudra De Alwis, Director during the visit.
LPA previously conducted interviews of children in attendance at the school, a staff member and parents. Based on the information obtained, LPA has concluded that the above listed allegation is - SUBSTANTIATED. A finding of "Substantiated" means that based on the LPA's interviews and other information obtained, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 12 are being cited on the attached LIC9099D. The attached, Type "A" deficiency is being cited and must be corrected by the due date.

NOTICE: Upon receipt: LICENSEE SHALL POST AND PROVIDE COPIES OF THIS LICENSING REPORT TO PARENTS/GUARDIANS OF CHILDREN IN CARE AT THE FACILITY AND TO PARENTS/GUARDIANS - CONTINUED ON LIC 9099 C/D

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen Redmond	TELEPHONE: (510) 873-6410
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

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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Control Number 02-CC-20190506141751

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: A LITTLE WORLD MONTESSORI ACADEMY	FACILITY NUMBER: 073405005
	VISIT DATE: 05/22/2019

NARRATIVE

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NEWLY ENROLLED AT THE FACILITY DURING THE NEXT 12 MONTHS. ALL PARENTS/GUARDIANS MUST SIGN AN ACKNOWLEDGMENT FORM OF PROOF OF REVIEWING THIS REPORT (LIC 9224). THE LIC 9224 MUST BE PLACED IN THE CHILD'S FILE TO BE REVIEWED BY LICENSING.

FAX POC AND COPIES OF LIC 9224 TO ATTN: LPA REDMOND (510)622-2641 BY POC DUE DATE.

Exit interview conducted. Director was provided a Complaint Investigation Report, Plan of Correction (POC), which, she refused to sign. A copy of their Appeal Rights was also provided. This report must be kept available for public review for three (3) years. Notice of Site Visit shall be posted upon receipt and shall remain posted for 30 days. Failure to do so may result in Civil Penalties of $100 per per day per violation.

SUPERVISOR'S NAME: Antranette Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen Redmond	TELEPHONE: (510) 873-6410
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

LIC9099 (FAS) - (06/04)

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Control Number 02-CC-20190506141751

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: A LITTLE WORLD MONTESSORI ACADEMY	FACILITY NUMBER: 073405005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/23/2019 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	Personal Rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to...(See section cited). LICENSEE DID NOT MEET THIS REQUIREMENT: BASED ON LPA INTER	1 2 3 4 5 6 7	LICENSEE WILL: 1) Provide training to staff persons (S1) and (S2) on Personal Rights. Staff shall issue a written, signed and dated statement explaining the purpose of Personal Rights and the impact to a child who has suffered from violation of 101223(a)(3). 2) All staff are to review all training videos
	8 9 10 11 12 13 14	VIEWS, STAFF PERSONS (S1) AND (S2) HIT A CHILD IN CARE. THIS IS AN IMMEDIATE THREAT TO THE HEALTH AND SAFETY OF CHILDREN IN CARE.	8 9 10 11 12 13 14	on the ccld.ca.gov, website for child cares. After reviewing the videos, they are to submit a written statement of completion, AND a statement that they intend to comply with the Personal Rights of children. The statement shall be signed and dated and sent to LPA by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Robinson	TELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen Redmond	TELEPHONE: (510) 873-6410
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

LIC9099 (FAS) - (06/04)

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