093614550-10-17-2022-03-CC-AMAT-CKAM2Q-20221017091355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093614550
Report Date: 10/13/2022
Date Signed: 10/17/2022 09:14:21 AM

Document Has Been Signed on 10/17/2022 09:14 AM - 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	PINE TOP MONTESSORI SCHOOL		FACILITY NUMBER:	093614550
ADMINISTRATOR:	KIME, JILL		FACILITY TYPE:	850
ADDRESS:	6526 PONY EXPRESS TRAIL		TELEPHONE:	(530) 903-3106
CITY:	POLLOCK PINES	STATE: CA	ZIP CODE:	95726
CAPACITY:	30	CENSUS: 6	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Carrie Molaug		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On Thursday October 13th, 2022, Licensing Program Analysts (LPAs) Arianna Manabat and Soleil Marx met with Facility Representative Carrie Molaug for an unannounced annual inspection. At 11:55 AM, LPAs toured the facility including all activity and classroom spaces, restrooms, food service and outdoor play areas. Census included 6 preschool children in care with 3 staff; one a fully qualified staff. Facility Representative was reminded never to exceed the conditions, limitations and capacity specified on the license. Facility hours of operation are Monday through Friday 8:00 AM to 5:00 PM. Facility Representative 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. Classrooms all appeared clean including the carpets and floor. Chemicals and cleaning materials were kept inaccessible to children. Playground equipment and surfaces were inspected during today's visit. Please see 809-D for information pertaining to this information. Drinking water was readily available to children both indoors and outdoors in water bottles. Shade was provided via trees. Bathrooms were clean and all sinks and toilets were in operating condition. The facility representative stated that there are no firearms or bodies of water on the premises and the facility has at least one functioning smoke and carbon monoxide detector. Menus were posted for AM and PM snack and the children bring their lunches. LPAs observed the appropriate postings were visible to parents. LPAs observed a current children's roster and a fire/disaster drill log. The facility is equipped with First Aid equipment. LPAs observed parents are signing their children in and out of the center. *Continued on LIC 809-C.....*

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna Manabat	TELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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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Document Has Been Signed on 10/17/2022 09:14 AM - 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PINE TOP MONTESSORI SCHOOL	FACILITY NUMBER: 093614550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101238.2(c)

Outdoor Activity Space

(c) Equipment and activity areas shall be arranged so that there is no hazard from conflicting activities. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA's Manabat and Marx observed play equipment that poses an immediate health and safety risk to children in care as evidenced by playground equipment missing several bolts which are used to connect the structure's play tunnnel to the main play structure component. LPA Manabat and Marx have documented the tunnel's ability to be separated from the main structure, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Facility will place the structure off-limits and provide proof of disposal of the climbing structure. The facility will also provide a maintence request documenting that the structure will be repaired or proof of the structure fixed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Natalie Dunaway	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna Manabat	TELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PINE TOP MONTESSORI SCHOOL	FACILITY NUMBER: 093614550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238.2(e)

Outdoor Activity Space

(e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and record review, LPAs found that there is not enough substrates under swings, slides, and climbling structures to absorb a fall. 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: 10/27/2022
	Plan of Correction
1 2 3 4	Facility will provide proof of documentation showing bark or other substrates ordered for the structures mentioned above.

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
1 2 3 4	Based on record review, two of the three staff members present have not obtained records of immunization within their employee records. The licensee did not comply with the section cited above in two out of three persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2022
	Plan of Correction
1 2 3 4	Facility will provide proof of immunizations for teachers to the Licensing Program Analyst.

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: Natalie Dunaway	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna Manabat	TELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2022 09:14 AM - 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PINE TOP MONTESSORI SCHOOL	FACILITY NUMBER: 093614550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101220.1(g)

Immunizations

(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as evidcenced by three out of the five files reviewed do not contain proof of immunizations for children within the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2022
	Plan of Correction
1 2 3 4	Facility will provide LPA with proof of immunizations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Natalie Dunaway	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna Manabat	TELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PINE TOP MONTESSORI SCHOOL	FACILITY NUMBER: 093614550
	VISIT DATE: 10/13/2022

NARRATIVE

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LPAs reviewed staff files and transcripts and observed all staff being utilized as full-qualified teachers were qualified. LPAs observed current Mandated Reporter certificates and proof of immunization for the staff. At least one staff had a current Pediatric CPR and First Aid certification. LPA observed the sample of children’s files contained the appropriate documentation.
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
All Child Care Centers (CCCs) that are located in buildings constructed before January 1, 2010 must have their drinking water tested for lead and post the results by January 1, 2023 and every 5 years after the date of the initial test. For a license issued on or after July 1, 2022, the CCC must have its water tested and post the results within 180 days of licensure.
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/inspection-process.
Facility Representative was encouraged to the visit the Department's websites and hrpertaining to child care centers.

Based on the inspection, four Title 22 Deficiencies have been issued on the attached LIC 809-D. The director was informed that this report documents one Type A citation which shall be posted for 30 consecutive days. The director shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Facility Representative has been provided with appeal rights. Exit interview conducted and report was reviewed with Facility Representative

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Arianna Manabat	TELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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