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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191804468
Report Date: 02/01/2023
Date Signed: 02/01/2023 12:18:13 PM


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:MONTESSORI SHIR-HASHIRIMFACILITY NUMBER:
191804468
ADMINISTRATOR:CIELAK, ELENAFACILITY TYPE:
850
ADDRESS:6047 CARLTON WAYTELEPHONE:
(323) 465-1638
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY:43CENSUS: 34DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Lidia Linares, Lead TeacherTIME COMPLETED:
12:35 PM
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On February 1, 2023, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Required 1 Year inspection. LPA met with Teacher, Lidia Linares, who guided LPA on a tour of the facility. This is a preschool program licensed for 43 children which operates Monday – Friday from 8:00 AM – 5:00 PM. Per Teacher there are currently 34 children enrolled. LPA observed 34 children with 5 staff.

All areas identified on the facility sketch were inspected. The following classrooms were inspected: Room 1: 19 children with 2 staff and Room 2: 16 children with 2 staff. Teacher-child ratios were observed and staff names were recorded. At 9:37AM, LPA observed Staff #1 (S1) go the restroom leaving Staff #4 (S4) alone with 16 children. At 9:56AM, LPA observed S1 and S4 outside with 2 children inside the classroom alone. The Licensee is within the conditions, limitations, and capacity specified on the license.

Furniture and equipment was inspected to ensure that they are in good condition, free of sharp, loose or pointed parts. LPA observed that all indoor classrooms are clean and safe. All toilets, hand washing, and bathing facilities are in safe and sanitary operating conditions. At 8:40AM, LPA observed children toilets in staff restroom. Per lead teacher, Lidia the children toilets were placed in the staff restroom to minimize the amount of children in restroom during the COVID-19 pandemic. Per lead teacher, Lidia there are no other staff restrooms. LPA informed lead teacher that children and staff are not allowed to use the same restroom. Per, lead teacher Lidia the children will go back to using the restroom that was licensed for children. At this time, the office is used as an isolation area. All materials and surfaces accessible to children are toxic free.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468
VISIT DATE: 02/01/2023
NARRATIVE
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Snack menus were reviewed. The facility provides AM snack and PM snack. Children bring their own lunches. All kitchen, food preparation, and storage areas are clean, free of litter, rubbish, and rodents/vermin. There is uncontaminated drinking water available in all indoor classrooms. All storage containers used for solid waste, including moveable bins have tight fitting lid at this time and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were observed to be accessible to children. The safety latches where the cleaning solutions are located are broken. LPA observed knives in the left drawer near the kitchen sink to be accessible to children in care; the safety latch is broken. Per lead teacher Lidia, children are allowed in the kitchen do conduct activities, but are with a staff at all times.

At 9:34AM, LPA observed S1 yelling at Child #1 (C1) and Child #3 (C3).

Outdoor play equipment was observed to be in safe condition, free of sharp loose or pointed parts. The outdoor activity space was observed to be in a safe condition, and is free of hazards. Areas around and/or under climbing equipment, have mulch as a cushioning material to absorb a fall. The licensee states that there are no bodies of water on the premises and LPA did not observe any bodies of water during this visit. Per Teacher there are no weapons or firearms on the premises. There is a carbon monoxide detector on site that meets statutory requirements.

Staff files were reviewed to ensure that each file contains a Personnel Record. Children’s Records were reviewed to ensure that each child has an Emergency and Identification form on file. Criminal Records Clearance for adults, Qualifications and verification of CPR/First Aid and health preventative practices documentation was reviewed. Staff #3 (S3) is not qualified to be an aide and S3 does not have any Child Development Units. Per S3, she provides care and supervision to the children while the teachers are on break, she assist with diaper changing and supervising the children during nap time.



LPA observed licensing board and did not see required forms posted, Facility License, LIC610 and PUB264.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468
VISIT DATE: 02/01/2023
NARRATIVE
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SB792 Immunization Requirements for Staff and Employees was discussed. Not all staff have current immunization documentation on file. LPA did not observed S1's TB Test. This is a potential risk to the health and safety of children in care.

AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/. Not all staff have completed the Mandated Reporter Training. This is a potential risk to the health and safety of children in care.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. A plan of operation for IMS must be submitted to the Department. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.htmL

REMINDER: Failure to obtain a criminal record background check clearances prior to initial presence in the facility will result in an immediate $100.00 dollar or more per day Civil Penalty. In order to associate an employee with a previous LiveScan, the following must be submitted to the Department, LIC 508, LIC 9182 and a copy of the person's identification. LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.



The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468
VISIT DATE: 02/01/2023
NARRATIVE
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The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Teacher, Lidia Linares. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101160(a)
Posting of License
(a) The license shall be posted in a prominent, publicly accessible location in the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility license is not posted for the public which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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2
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Lead teacher, Lidia stated the license will be posted by POC date (02/10/2023).
Type B
Section Cited
CCR
101169(d)(18)
Application for License
(18) Evidence that the applicant has posted signs at the entrance to the child care center that provide the telephone number of the local health department and information on child passenger restraint systems pursuant to Health and Safety Code section 1596.95(g) and Vehicle Code sections 27360 and 27360.5.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA did not observe the telephone number or the local health department and information on child passenger restraint system which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Lead teacher, Lidia stated the license will be posted by POC date (02/10/2023).
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 5 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in LPA did not observe disaster plan and lead teacher did not know where it was located which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Lead teacher, Lidia stated the license will be posted by POC date (02/10/2023).
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed cabinet under the kitchen sink to have broken safety latches leaving the cleanin solution accessible to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2023
Plan of Correction
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Staff member Silvia Morales removed all cleaning solutions and placed them in off limits garage.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 6 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229(a)(1)
Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed 2 children inside classroom #2 alone which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Teacher Marial Dilores came back into the class and took the children outside. LPA requests that director have a staff meeting about supervision and submit a copy of the sign in sheet to LPA on 02/10/2023.
Type B
Section Cited
CCR
101230(c)(1)
Activities/Napping
(c) A teacher-child ratio of one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio specified in Section 101216.3(a) are immediately available at the center. (1) An aide who is 18 years of age or older, and who meets the requirements of Sections 101216 and 101216.2, may supervise 24 napping children in place of a teacher if the conditions specified in
(c) above are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in Staff # 2 and Staff #3 stated that S3 supervises children during nap time alone. S3 is not a qualified aide which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2023
Plan of Correction
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Lead teacher, Lidia stated that S3 will no longer supervise children during nap time.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 7 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 in LPA did not observe training certificate for Staff #1, Staff #2 and Staff #3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Lead teacher, Lidia stated that all teachers/staff will have their Mandated Reporter training by POC date (02/17/2023).
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 in LPA did not observe TB test for Staff #1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Per lead teacher Lidia, Staff #1 will complete TB test by POC date (02/17/2023).
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 8 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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 in LPA did not observe Child #1 have a Physican Report in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
1
2
3
4
Per lead teacher Lidia, C1 will have Physicans Report completed by POC Date (02/17/2023).
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 in LPA did not observe immunizations for Child #1, Child #3 and Child #4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
1
2
3
4
Per lead teacher Lidia, C1, C3 and C4 will have immunizations by POC Date (02/10/2023).
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 9 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

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 in LPA did not observe LIC613A in Child #1, Child #2, Child #3 and Child #4 file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
1
2
3
4
Per lead teacher Lidia, C1, C2, C3 and C4 will have a signed copy of LIC613A by POC date (02/03/2023).
Type B
Section Cited
CCR
101216.3(a)
Teacher-Child Ratio
(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed Staff #4 being left alone with 16 children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
1
2
3
4
Teacher Marial Dilores came back into the class and assisted S4 with supervison. LPA requests that director have a staff meeting about supervision and submit a copy of the sign in sheet to LPA on 02/10/2023.
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 10 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.3(h)
Teacher-Child Ratio
(h) Persons employed for clerical, housekeeping and maintenance functions shall not be included as teachers in the teacher-child ratio.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in Staff #3 has been providing care and supervison when she is not a qualified aide which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
1
2
3
4
Aide qulaifications were explained to Staff #3 and lead teacher Lidia. Per Lidia, S3 will not be providing care and supervision to children. LPA request that director hold a meeting with staff reviewing teacher qulaifications and aide qualifications. A copy of sign in sheet is to be provided to LPA by POC date (02/10/2023).
Type B
Section Cited
CCR
101223(a)(1)
Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA heard Staff #1 yelling at Child #1 and Child #3 in front of the class and Staff #4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
1
2
3
4
Lead teacher Lidia will talk to Staff #1. LPA request that director hold a meeting with staff reviewing personal rights. A copy of sign in sheet is to be provided to LPA by POC date (02/10/2023).
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 11 of 13


Document Has Been Signed on 02/01/2023 12:18 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: MONTESSORI SHIR-HASHIRIM
FACILITY NUMBER: 191804468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101223(a)(3)
Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA heard Staff #1 tell Staff #4 what Child #1 and Child #3 did and starting asking the rest of the children if that was appropriate. LPA observed Child #1 and Child #2 put their heads down which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
1
2
3
4
Lead teacher Lidia will talk to Staff #1. LPA request that director hold a meeting with staff reviewing personal rights. A copy of sign in sheet is to be provided to LPA by POC date (02/10/2023).
Type B
Section Cited
CCR
101239(i)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in LPA observed 2 children toilets that were added to the staff restroom along with an additional sink for children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
1
2
3
4
Per lead teacher Lidia, children will stop using staff restroom and go back to using children's restroom. A copy of sign in sheet is to be provided to LPA by POC date (02/10/2023).
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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica AyalaTELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 12 of 13