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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408869
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:17:23 PM


Document Has Been Signed on 06/29/2022 02:17 PM - It Cannot Be Edited

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:KEYSTONE MONTESSORI SCHOOLFACILITY NUMBER:
073408869
ADMINISTRATOR:PATHAK, ROHINIFACILITY TYPE:
850
ADDRESS:6639 BLAKE STREETTELEPHONE:
(510) 709-5853
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:57CENSUS: 43DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Denise MorrisTIME COMPLETED:
02:30 PM
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On 06/29/22 at 9:30AM, Licensing Program Analysts (LPAs) Christina Watts and Morgan Pringle conducted an unannounced Annual Inspection at Keystone Montessori School. LPAs met with Assistant Director, Denise Morris and Director, Rohini Pathak. LPAs explained the purpose of today's inspection. Facility's operating days and hours are Monday to Friday from 8:00 am - 5:45 pm in 3 classrooms (Snowny Egret, Blue Herin and Sandpiper) During today's inspection, there were 43 children in care and 52 children enrolled in the facility. Also, there is 12 staff in the facility during inspection. Facility currently has toddler component. (Sandpiper room)

The physical plant was inspected. LPA stoured the premises with the Assistant Director, Denise Morris.
Indoor space: 3 classrooms, 3 restrooms, and kitchen were inspected. During inspection, children were engaged in different activities. Disinfectants, cleaning solutions, and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restrooms for children were observed to be in safe, sanitary, and functioning condition. Floors were clean and free from tripping hazard. Foods and beverages were stored safely. Food storage area were clean, free of litter, rubbish, and rodents/vermin. Trash cans for solid waste had tight-fitting covers and were in good repair. LPA observed a working Fire extinguisher, Smoke and Carbon Monoxide Detectors. Log shows that the last Fire Drill was conducted on March 5, 2022. Facility does not provide transportation for children, but Director understands that children cannot be left alone, unattended in parked vehicles. Facility’s License, Parents’ Rights Poster PUB 393, Personal Rights, Activity Schedules, and Menus were observed to be posted.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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: KEYSTONE MONTESSORI SCHOOL
FACILITY NUMBER: 073408869
VISIT DATE: 06/29/2022
NARRATIVE
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Outdoor Space: Outdoor playground was inspected and observed to be fenced and safe. The play equipment was maintained in good condition and free of hazards. LPAs observed 4 different sections separated by a fence. One section has a a set of swings and a sandbox. Another section had a play structure with a climbing wall. The middle sections is for celebrations but mainly used for tricycles. The toddlers have their own play area with age appropriate toys and a sandbox. Areas around and under high climbing equipment and slides were cushioned with material that absorbs falls. Shade is provided by way of covered areas. There were no bodies of water observed. Drinking water is arranged to be readily available to children during indoor and outdoor activities.

File Review: Children sign in and out procedures and logs were reviewed. Facility uses manual sign in/sign out procedure as well as Transparent classroom app. LPAs reminded facility to maintain sign in/sign out procedures and make sure parents/authorized representatives sign the child in and out. A sampling of Children and Staff files was taken for review. All files contained required documents. There was at least one Teacher with current certification in Pediatric CPR/First Aid present at the facility during inspection. Children's Roster was reviewed, and a copy obtained.



On or before March 30, 2018 any person who works in a child care facility shall complete Mandated Reporter training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: KEYSTONE MONTESSORI SCHOOL
FACILITY NUMBER: 073408869
VISIT DATE: 06/29/2022
NARRATIVE
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Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/ction-process.

In the areas that were evaluated, 2 Type B violations were observed. Also a technical violation was given for failure to complete the Mandated Reporter-Child Care Providers section.

DEFICIENCY CITED:
1596.7995(a)(1):Failure to have immunization's in employee file
101217(a)(12): Failure to have Tuberculosis record in employees file.

At 1:30pm, Exit interview conducted and report was reviewed with the Assistant Director Denise Morris and Director, Rohini Pathak. A Notice of Site Visit was given and must remain posted for 30 consecutive days.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/29/2022 02:17 PM - It Cannot Be Edited

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: KEYSTONE MONTESSORI SCHOOL
FACILITY NUMBER: 073408869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Director will submit proof of immunizations by end of business 07/06/2022
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Director will submit proof of immunizations by end of business 07/06/2022

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: Sherelle JohnsonTELEPHONE: (510) 421-3587
LICENSING EVALUATOR NAME: Christina WattsTELEPHONE: (510) 246-1797
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5