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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015582
Report Date: 02/07/2024
Date Signed: 02/07/2024 10:33:44 AM


Document Has Been Signed on 02/07/2024 10:33 AM - 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:MONTESSORI SCHOOL OF SAN DIMASFACILITY NUMBER:
198015582
ADMINISTRATOR:FAMEEDA CASSIMFACILITY TYPE:
850
ADDRESS:730 E. FOOTHILL BLVD.TELEPHONE:
(909) 599-7774
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:73CENSUS: 20DATE:
02/07/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Fameeda CassimTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analysts (LPA) Jennifer Hua conducted an unannounced case management inspection on 2/7/2024. A COVID 19 risk assessment was conducted. LPA met with director/licensee Fameeda Cassim, the purpose of the visit was announced.

The purpose of today's inspection is to go over the water lead test results received on 01/30/2024. Results indicate that "A”, “B”, "D" and "E" water source had action level exceedance of lead. The "A" water source located in room #1 had a lead result of 29, the “B” water source located in room #1 had a lead result of 7.4, the "D" water source located in room #2 had a lead result of 6.6 and the "E" water source located in room #2 had a lead result of 5.6. Per director, outlets "B" and "E" are sink faucets that are and have been used for hand washing only. Outlets "A" and "D" are drinking fountains that have been capped and pipes have been removed. LPA observed signs by faucets "B" and "E" is to be used for hand washing only. LPA observed drinking fountains "A" and "D" have been capped and pipes have been removed, photos were also received. LPA also observed bottled water in the classroom cabinet. Per director, ceased using drinking fountains as soon as results were received, but previous to that date, children had access. Per director, children bring their own water bottle and facility also purchased additional bottled water for drinking. Director also stated that bottled water are also refilled from an outlet in the kitchen that had no deterrence. LPA advised director to review PIN 21-21.1-CCP (Written Directives for Lead Testing of Water).

A deficiency is cited on attached 809D.

An exit interview conducted with director. Notice of Site Visit form was provided and must be posted for 30 days in an area accessible for review.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/07/2024 10:33 AM - 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: MONTESSORI SCHOOL OF SAN DIMAS
FACILITY NUMBER: 198015582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2024
Section Cited
CCR
101700.3(c)

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California Lead Action Level at Child Care Centers. Licensee failed to maintain a lead value at or below the Action Level for water lead testing of 5.5 ppb or greater for outlet "A", "B", "D" & "E". Result with values of 5.5 ppb or greater shall be deemed an Action Level
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Per director, exceedence have been remedied. Outlets "B" & "E" (sink faucets) are use for handwashing only. Outlets "A" & "D" (drinking fountains) have been capped and pipes removed.

Deficiency has been corrected
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This requirement is not met as evidenced by: Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink. This poses a potential Health and Safety risk
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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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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