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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406649
Report Date: 05/24/2019
Date Signed: 05/24/2019 12:02:21 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 SCHOOLFACILITY NUMBER:
073406649
ADMINISTRATOR:ELAINE SALDIVARFACILITY TYPE:
850
ADDRESS:324 37TH STTELEPHONE:
(510) 412-2244
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY:55CENSUS: 5DATE:
05/24/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hikkaduwa DeAlwisTIME COMPLETED:
12:05 PM
NARRATIVE
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LPAs Dayna Collier and Diana Campos met with Center Director Hikkaduwa DeAlwis for a case management inspection. Present for the inspection were the Director, one staff member and 5 children in care. An incident occurred alleging a violation of a child's personal rights. This incident was not reported to Licensing.

The attached type B deficiency is cited today and must be corrected by the due date. This report must be available for public review for 3 years. An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted by LPA.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: A LITTLE WORLD MONTESSORI SCHOOL
FACILITY NUMBER: 073406649
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2019
Section Cited
CCR
101212(d)
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101212 Reporting Requirements

(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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 following the occurrence of such event.
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POC: By 5/31/19, a written unusual incident report will be completed and forwarded to Licensing.
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This requirement was not met as evidenced by interviews conducted. This poses a potential risk to the health and safety of children.
THE FACILITY FAILED TO REPORT AN UNUSUAL INCIDENT TO LICENSING.
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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: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2019
LIC809 (FAS) - (06/04)
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