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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198009436
Report Date: 09/24/2021
Date Signed: 09/24/2021 11:35:17 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:INTERNATIONAL MONTESSORI ACADEMY - WEST CAMPUSFACILITY NUMBER:
198009436
ADMINISTRATOR:MONICA MENDOZAFACILITY TYPE:
850
ADDRESS:355 GREEN ST.TELEPHONE:
(626) 792-4505
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY:92CENSUS: 62DATE:
09/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yancy Gamez Martinez , Assistant DirectorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted a case management inspection due to an incident that occurred on 06/04/19. LPA met Assistant Director, Yancy Gamez Martinez who guided LPA on a tour of the facility at approximately 09:30 AM. During this inspection LPA observed 23 children with 02 staff in the lower playground. 23 children with 02 staff in the upper playground. In classroom# One, 06 children with 01 staff, in classroom# Two, 10 children with 01 staff.

The incident that occurred on 06/04/19 was reported to the Department on 06/05/19. The facility reported the incident in a timely manner.

LPA conducted an interview with S1. LPA also visually observed the space where the incident occurred.

On 06/04/19 a child in the upper playground was sliding down on the slide and tripped on the mat frame landing on his right arm which resulted in child having a hair line fracture. The injury required medical attention leading to the child wearing a cast for three weeks. LPA observed the area where the child tripped, LPA observed the bottom of the slide. LPA observed that there is a foam mat that is secured on the ground with foam chips all around the play structure that can absorb a child's fall. Per director children are reminded of the play structure safety rules and are redirected to play safe.

Based on all information obtained on this date, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
Exit interview was conducted with Yancy Gamez Martinez, Appeal rights explained & provided.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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