198009436-4-8-2022-33-CC-FVAZ-CDASA7-20220408134153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198009436
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:42:00 PM

Document Has Been Signed on 04/08/2022 01:42 PM - It Cannot Be Edited

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 CAMPUS		FACILITY NUMBER:	198009436
ADMINISTRATOR:	MONICA MENDOZA		FACILITY TYPE:	850
ADDRESS:	355 GREEN ST.		TELEPHONE:	(626) 792-4505
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY:	92	CENSUS: 60	DATE:	04/08/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Yolanda Sollitto, Director		TIME COMPLETED:	01:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fabiola Vasquez conducted a case management inspection due to an incident that occurred on 03/04/22. LPA met Yolanda Sollitto, Director who guided LPA on a tour of the facility at approximately 08:40 AM. During the guide LPA observed the drop of time procedures. Parents drive in with their cars on the backside of the school through the lower children's playground to the front of the school where staff receive and walk the children to the classrooms. Per director this is only done for the arrival time 8:00 to 9:05AM. LPA observed in classroom# One, 08 children with 01 staff, classroom# Two, 11 children with 01 staff, Three 12 children with 01 staff, Four, 11 children with 01 staff, Five, 12 children with 02 staff. Upon arrival. Per director the incident that was reported dated for 04/03/22 on the LIC 624 is incorrect the incident occurred on 03/04/22. The incident date was 03/04/22 was reported to the Department on 03/08/22. The facility reported the incident in a timely manner. LPA conducted an interview with S1, S2, S3, C1. LPA also visually observed the space where the incident occurred. LPA obtained a copy of the accident report provided to the parent. On 03/04/22 a child climb the rock wall upstairs structure. He ran through the structure toward the structure bridge. He was not looking forward and hit his right side of his head on the edge of the roof. The injury required medical attention leading to the child receiving stitches. Based on LPA's observations and statements disclosed during interviews with S1, S2, S3 and C1. Statements made by S2, S3 that child C1 climb up the rock wall and hurt his head on the top by the apparatus bridge. C1 stated while pointing that's where I jumped and hit my head which is located on a different part of the apparatus stated by S2 and S3. Other statements made by S2 and S3 that they did not see when C1 hurt his head, children were asked about the incident. PAGE 1 OF 2

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola Vasquez	TELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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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Document Has Been Signed on 04/08/2022 01:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CAMPUS	FACILITY NUMBER: 198009436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2022 Section Cited	1 2 3 4 5 6 7	a)The licensee shall ensure that each child is accorded the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations * This requirement is not met as evidenced by: :
	8 9 10 11 12 13 14	Statements made by S2, S3 that child C1 climb up the rock wall and hurt his head on the top by the apparatus bridge. C1 stated while pointing that's where Ijumped and hit my head which is located on a different part of the apparatus stated by S2 and S3.	8 9 10 11 12 13 14	Other statements made by S2 and S3 that they did not see when C1 hurt his head, children were asked about the incident. This poses an immediate risk to the health and safety of children in care.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola Vasquez	TELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CAMPUS	FACILITY NUMBER: 198009436
	VISIT DATE: 04/08/2022

NARRATIVE

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Based upon information received from the interviews conducted it was determined that the personal rights of C1 were violated. This was an immediate risk to the health and safety of children in care.
The following deficiencies listed on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee/Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

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 Yolanda Sollitto, Director, including, but not limited to Provider Rights, Appeal Procedures

California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, Section 101223 "Personal Rights" is being cited on the attached LIC 9099D.

Department is working with director on the arrival procedures (see page 1 of the report). LPA reviewed previous annual visits the arrival procedures have not been observed other LPA's. An alternative drop off procedure needs to be submitted by 04/15/22 to LPA.

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SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola Vasquez	TELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC809 (FAS) - (06/04)

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