198015582-8-10-2021-33-CC-BBAT-C5RNSQ-20210810104331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198015582
Report Date: 08/10/2021
Date Signed: 08/10/2021 10:43:37 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 SCHOOL OF SAN DIMAS		FACILITY NUMBER:	198015582
ADMINISTRATOR:	FAMEEDA CASSIM		FACILITY TYPE:	850
ADDRESS:	730 E. FOOTHILL BLVD.		TELEPHONE:	(909) 599-7774
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	73	CENSUS: 21	DATE:	08/10/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Director, Diana Ramirez		TIME COMPLETED:	10:45 AM

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	An unannounced Case Management Inspection was conducted on this day by Licensing Program Analyst (LPA) Bardo Baluyot to address an Unusual Incident Report that was received in the licensing office on 4/29/2021. LPA met with Director, Diana Ramirez who guided LPA on a tour of facility of both indoors and outdoors. Child 1 is a five year old toddler who broke her arm. On 4/28/2021, during outdoor play, Child 1 jumped off a platform leading to the monkey bars and landed in a seated position with her left arm behind her back. Per Staff 1, children typically stand at the platform before using the monkey bars but on this day, Child 1 took a running start. Per Staff 1, she called out to Child 1 not to run but Child 1 was already mid-flight. Per Staff 1, Child 1 was crying and her left arm appeared red and swollen. Per Staff 1, they comforted the child, applied ice and called the child's mother immediately. Mother arrived within 10 minutes and took the child to Kaiser's emergency room. X-rays revealed radius (wrist bone) fracture, ulna (wrist bone) fracture, ulna (lower arm bone) fracture, radial head (elbow ) dislocation. Per Director, Child 1 was placed in a cast for approximately 7-8 weeks and regained full use of her arm. Child's last day at the facility was 7/30/21. Child left to attend Kindergarten at the local public school. Based on all information obtained on this date, and interviews conducted with staff, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. LPA observed the play structure including the platform to be in good condition and had no visible tripping hazards. Director confirmed that staff are always stationed at or near the platform during outdoor play and were reminded to be more diligent with instructing children not to run on play structure. Aside from the aforementioned advisory, It appears to be nothing that the facility staff could have done to prevent the incident from occurring. There were no deficiencies observed in regards to today's visit.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo Baluyot	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

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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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: MONTESSORI SCHOOL OF SAN DIMAS	FACILITY NUMBER: 198015582
	VISIT DATE: 08/10/2021

NARRATIVE

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The Director was advised that inaccessibility of hazards must be constantly reassessed and reviewed with staff depending on the children in care.

Exit interview was conducted with Director, Diana Ramirez. A copy of this report along with Appeal Rights were provided and Appeal Rights explained.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo Baluyot	TELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC809 (FAS) - (06/04)

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