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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004486
Report Date: 11/22/2021
Date Signed: 11/22/2021 11:37:36 AM

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 ACADEMYFACILITY NUMBER:
198004486
ADMINISTRATOR:BIBILE, NIRANJALAFACILITY TYPE:
850
ADDRESS:1920 W. GLENOAKS BOULEVARDTELEPHONE:
(818) 841-9096
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:85CENSUS: 25DATE:
11/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Niranjala Biblie, licenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management- incident inspection to the above facility on 11/22/2021. LPA arrived at the facility at 9:00 AM and met with Joeliza Dangana, teacher. Shortly after Niranjala Biblie, director arrived to the facility who guided analyst on a tour of the facility. During this inspection there were 25 children present in the facility with four staff.

Alleged Incident took place on 11/15/2021. Incident was reported via telephone next working day 11/16/2021. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The written incident report was dropped off in person on Wednesday 11/17/2021 . The incident report was dated for 11/17/2021. The facility reported the incident within the required 24 hour time frame.

During this inspection LPA conducted interviews with five staff. LPA obtained a copy of Child#1 file.

Ratio and staffing were in accordance of Title 22 Code of Regulations at the time of the incident.

At this time, the above incident require additional information to conclude this investigation. LPA will conduct a follow up inspection. No deficiencies were cited on this date.

The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the director Nirajala Bibile, director, at 12:00 p.m..
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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