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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417397
Report Date: 12/13/2019
Date Signed: 12/13/2019 03:53:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:MONTESSORI OF VALENCIAFACILITY NUMBER:
197417397
ADMINISTRATOR:ERIN JOHNSONFACILITY TYPE:
830
ADDRESS:24925 ANZA DRIVETELEPHONE:
(661) 257-4161
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:24CENSUS: 18DATE:
12/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Erin Johnson TIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Victoria Hunt met with Director, Erin Johnson for the purpose of a Case Management - Incident inspection for an unusual incident. This incident was reported by director on 12/09/19 to the Palmdale CCLD. The unusual incident was reported and submitted timely.

Description of Incident - An unusual incident occurred concerning a 16-month-old infant who sustained an injury to the left-side of neck and cheek areas. During today's inspection. LPA conducted interviews with the staff 1,2, and 3. A copy of the accident report along with other pertinent documents were obtained.

Further investigation is needed regarding the incident. A final determination has not been made surrounding this incident. No deficiencies were cited during today's visit. A copy of this report was read and discussed with the director.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Victoria HuntTELEPHONE: (661) 568-8930
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2019
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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