093614550-9-27-2023-03-CC-NDUY-CW8ND7-20231002102149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 093614550
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:29:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2023 and conducted by Evaluator Soleil Marx

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20230818130607

FACILITY NAME:	PINE TOP MONTESSORI SCHOOL		FACILITY NUMBER:	093614550
ADMINISTRATOR:	JILL KIME		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:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Carrie Molaug		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Authorized representatives were not notified by staff about a field trip.
Staff did not have day care children's emergency contact/medical information available while on a field trip.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Soleil Marx, met with Facility Representative, Carrie Molaug, for the purpose of delivering findings to a complaint investigation alleging that authorized representatives were not notified by staff about a field trip and that staff did not have day care children's emergency contact/medical information available while on a field trip.Through the course of the investigation, LPA made observations of the facility, field trip site, and walking route. LPA conducted interviews with the Director, staff, and parents. LPA obtained and reviewed relevant records to the allegations.It was determined that the facility took children off the premises to go on a field trip to the park and did not notify authorized representatives, which is in violation of the facilities admission agreement which states that all field trips will be located offsite and will be publicized well in advance. It was determined by interview that the facility did not bring medical consent forms with them while on a field trip off the premises, they were left at the facility. Based on interview and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Title 22 deficiencies are being cited on LIC 9099D.Exit interview conducted and report reviewed with Facility Representative, Carrie Molaug. Appeal rights provided. Notice of site visit was given and must remain posted for 30 days.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2023 and conducted by Evaluator Soleil Marx

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20230818130607

FACILITY NAME:	PINE TOP MONTESSORI SCHOOL		FACILITY NUMBER:	093614550
ADMINISTRATOR:	JILL KIME		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:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Carrie Molaug		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not adequately supervise day care children resulting in children getting hit by a vehicle while on a field trip.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Soleil Marx, met with Facility Representative, Carrie Molaug, for the purpose of delivering findings to a complaint investigation alleging that staff did not adequately supervise day care children resulting in children getting hit by a vehicle while on a field trip.
Through the course of the investigation, LPA made observations of the facility, field trip site, and walking route. LPA conducted interviews with the Director, staff, and parents. LPA obtained and reviewed relevant records to the incident and allegation.
It was learned through interview that staff do a trial walk with children on-site prior to leaving the premises for a field trip to make sure everyone is being safe and calm, children walk in a line using a buddy system to pair an older child with a younger child, and that one staff leads the front of the line, while the other staff follows the back of the line. LPA determined through observation, interview, and record review of police report, that staff waited for a break in traffic before entering the designated crosswalk with children, staff attempted to stop the approaching vehicle, and attempted to quickly move children out of the roadway prior to the collision.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 03-CC-20230818130607

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PINE TOP MONTESSORI SCHOOL	FACILITY NUMBER: 093614550
	VISIT DATE: 09/27/2023

NARRATIVE

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LPA could not prove that staff did not adequately supervise day care children resulting in children getting hit by a vehicle while on a field trip. Although the allegations above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and report reviewed with Facility Representative, Carrie Molaug. Appeal rights provided. Notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 03-CC-20230818130607

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PINE TOP MONTESSORI SCHOOL	FACILITY NUMBER: 093614550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 10/11/2023 Section Cited CCR 101218(a)(5)	1 2 3 4 5 6 7	(a) child care center shall have all admission policies in writing and available to the public...The policies shall coincide with the limitations stated on the license, and shall include...:(5) Field-trip provisions, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility Representative stated they will update their admission policies, have parents re-sign the agreement, and submit to LPA Marx by POC due date.
	8 9 10 11 12 13 14	Based on record review, the licensee did not meet this requirement by not following the admission policies regarding field trip notification, which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Request Denied Type B 10/11/2023 Section Cited CCR 101226(c)(1)(A)	1 2 3 4 5 6 7	(1) The teacher supervising activities away from the center premises shall carry one of the following for each child engaged in such activities:(A)A signed consent form for emergency medical treatment This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility Representative stated they will update their red binder which goes on field trips to include childrens medical consent forms and will create a field trip check list and submit to LPA Marx by POC due date.
	8 9 10 11 12 13 14	Based on interview, the licensee did not meet this requirement by not bringing children's medical consent forms with them while on a field trip, which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

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