197414804-12-3-2019-17-CC-FPEA-BJHQGY-20191203111018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197414804
Report Date: 12/03/2019
Date Signed: 12/03/2019 11:10:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	MONTESSORI SCHOOL OF AGOURA		FACILITY NUMBER:	197414804
ADMINISTRATOR:	KUNSTLER, KAREN		FACILITY TYPE:	850
ADDRESS:	28124 DRIVER AVE.		TELEPHONE:	(818) 991-8936
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	57	CENSUS: 39	DATE:	12/03/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Karen Kunstler		TIME COMPLETED:	09:20 AM

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	Licensing Program Analyst (LPA) Frank Pedroza conducted an unannounced inspection for the purpose of conducting a Case Management. LPA met with facility Director Karen Kunstler and discussed the purpose of the inspection. LPA and Director conducted a tour of the facility inside and out. The facility had 39 children in care at the time of the inspection. On 10/29/2019, facility contacted Community Care Licensing (CCL) to self report an incident of a child (C1) sustaining an injury while in care. On 10/25/2019 at/or around 11:15 AM, the children were dancing in the classroom. C1 was spinning and slipped falling into a shelf in the classroom. C1 hit his head cutting himself and started to bleed. Teacher (T1) witnessed the incident occur and immediately went to assist C1. An ice pack was provided with a wet towel. C1's parents were contacted and his mother arrived shortly to take him to the Emergency Room (ER). C1 received two layers of dissolvable sutures and was released. He returned back to school on 10/29/19. The Doctor did not provide or require any restrictions that the facility would have to follow. Continued on 809-C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: MONTESSORI SCHOOL OF AGOURA	FACILITY NUMBER: 197414804
	VISIT DATE: 12/03/2019

NARRATIVE

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LPA observed where the child had fallen. Given the Director account of the incident when reporting it to CCL and how they addressed the incident, LPA deemed Director's action was appropriate.

No deficiencies were cited during today's visit.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

LIC809 (FAS) - (06/04)

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