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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090319030
Report Date: 09/24/2019
Date Signed: 09/24/2019 02:27:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MONTESSORI MANORFACILITY NUMBER:
090319030
ADMINISTRATOR:DILLON, LESLIEFACILITY TYPE:
850
ADDRESS:2222 FRANCISCO DR., STE. 400TELEPHONE:
(916) 933-2420
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:58CENSUS: 48DATE:
09/24/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Leslie Dillon - DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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An unannounced case management inspection was conducted today by Licensing Program Analyst Owens and Blesi. The purpose of the inspection is to cite a deficiency that was observed during a complaint investigation,

See deficiency on 809-D
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: MONTESSORI MANOR
FACILITY NUMBER: 090319030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2019
Section Cited

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Reporting Requirements:
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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This requirement was not met by:
Director failed to report an incident to CCLD of a child wandering away from the facility. This is a potential risk to a child.
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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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2