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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073405005
Report Date:
06/23/2021
Date Signed:
06/23/2021 02:44:30 PM
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:
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:
2
DATE:
06/23/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Samudra De Alwis
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Case Management Inspection. There were two children and one staff when LPA arrived. Samudra De Alwis arrived at the facility shortly after LPA's arrival.
During the annual inspection on 6/22/21 LPA's computer did a consistency check which prevented LPA from obtaining signatures on the report and printing the report. During today's inspection LPA obtained signatures and printed the annual inspection reports from 6/22/21.
There are no deficiencies cited today.
Exit interview was conducted with Samudra De Alwis.
Appeal Rights were provided.
Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISOR'S NAME:
Sherelle Johnson
TELEPHONE:
(510) 622-2592
LICENSING EVALUATOR NAME:
Cherie Acosta
TELEPHONE:
(510) 622-1623
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2021
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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