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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416245
Report Date: 09/13/2019
Date Signed: 09/13/2019 12:14:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MONTESSORI PRESCHOOLFACILITY NUMBER:
197416245
ADMINISTRATOR:LUZ IRIARTE GUTIERREZFACILITY TYPE:
850
ADDRESS:4024 WADE STREETTELEPHONE:
(310) 305-0226
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:30CENSUS: 23DATE:
09/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Virginia WikkramatillakkeTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Christopher Garlington and Claudia Escobedo met with Licensee Virginia Wikkramatillakke for the purpose of conducting a Case Management Visit to investigate the Unusual Incident Report that occurred on 07/19/2019.

On 07/19/19, the facility reported an unusual incident/injury via telephone and on 07 22/19 a copy of the Unusual Incident Report was faxed to the El Segundo Regional Office., involving a Child #1 who was scratched on the eye.



LPA Claudia Escobedo interviewed Child #1, Staff #1 and Staff #2. LPA Christopher Garlington interviewed Parent #1 and Parent #2 over the telephone.

Child #1 was treated and released at Kaiser West Los Angeles on the day of the incident and has no lasting effects according to Parent #1.

LPA has determined that the staff of the facility was present supervising the children at the the time of the incident and there is no need for further investigation.
SUPERVISOR'S NAME: Sharalyn Jenkins-SweetenTELEPHONE: (424) 301-3054
LICENSING EVALUATOR NAME: Christopher GarlingtonTELEPHONE: (424) 301-3056
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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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