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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419166
Report Date: 01/09/2020
Date Signed: 01/09/2020 01:45:02 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 STEVENSON RANCHFACILITY NUMBER:
197419166
ADMINISTRATOR:ELLISON, DESIREEFACILITY TYPE:
850
ADDRESS:25940 THE OLD ROADTELEPHONE:
(661) 257-4161
CITY:STEVENSON RANCHSTATE: CAZIP CODE:
91381
CAPACITY:188CENSUS: 63DATE:
01/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rushani Thomas-WiseTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Neal met with Director, Rushani Thomas-Wise and conducted a Case Management inspection on an Unusual Incident reported to Licensing on January 6, 2020. This incident was self -reported.

Description of the incident: On January 3, 2020, staff was informed that Child #1 disclosed being handled in a rough manner by a staff member. Date is unknown. Per staff, an internal investigation was conducted.

LPA Neal interviewed children, staff and other parties regarding the incident. Staff and child's file were reviewed and roster of children in care was obtained. Based on information provided, further follow-up will be needed.

No deficiencies were cited during this inspection.

Notice of site visit was given to be posted for 30 days.
Exit interview was conducted, report was read and a copy was given to the director.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Jazelle NealTELEPHONE: (661) 568-8945
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
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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