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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018405
Report Date: 06/16/2021
Date Signed: 06/16/2021 02:30:27 PM

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:KEYSTONE MONTESSORI PRESCHOOLFACILITY NUMBER:
198018405
ADMINISTRATOR:BHAGYA WIJEWARDANEFACILITY TYPE:
850
ADDRESS:7056 WASHINGTON AVE.TELEPHONE:
(562) 303-7273
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:53CENSUS: 16DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:BHAGYA WIJEWARDANETIME COMPLETED:
02:45 PM
NARRATIVE
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On 6/16/2021, at 8:45 a.m., Licensing Program Analyst (LPA) Alanna Gontarek conducted an unannounced Annual Inspection. Upon entry, LPA was greeted by maintenance staff and allowed into facility. Licensee/Director BHAGYA WIJEWARDANE arrived to facility at 9:23 a.m. LPA disclosed the purpose of the inspection, and was given a tour of the facility, indoors and outdoors. There were 16 children and two (2) staff present in the facility during this inspection. Facility operation hours are Monday to Friday from 07:00 a.m. to 06:00 p.m. LPA observed staff and children wearing face masks, during this inspection, due to COVID-19 preventative measures. The licensee does not exceed the conditions, limitations, or capacity
specified on the license.

All areas identified on the Facility Sketch were inspected. Upon arrival, the following staff were present during this inspection: Room 112 (3 to 5 Year Old Classroom): Staff #1 with 9 preschool children; Room 117 (2 to 4 Year Old Classroom): Staff #2 with 7 preschool children. The following was observed during the tour of the facility:

PHYSICAL PLANT


Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubbies to store their belongings. Linens are taken home each week to be washed. Per Licensee/Director, cots are sanitized weekly. Napping equipment (cots) were observed in each room. Per Licensee/Director, the isolation area is located in the office, located upstairs. Age appropriate sinks and toilets were inspected for availability and good repair in all restrooms. General sanitation was observed. Availability of indoor drinking water was observed in classrooms. LPA observed children have their own water bottles. LPA also observed filtered water, attached to the sink, and disposable cups. LPA observed First Aid Kits and labeled Emergency bags (per child
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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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 6
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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2021
Section Cited

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Food Services (a) In child care centers providing meals to children, the following shall apply:(8)...All foods shall be ...stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. This requirement was not met as evidenced by: LPA observed
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children's snack items, in dry storage room, Goldfish and Cheezits, to be opened from their original containers and not sealed nor labeled with expirations. This poses a potential risk to the health and safety of children in care.
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Type B
06/21/2021
Section Cited

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Food Services (a) In child care centers providing meals to children, the following shall apply: (19) All food shall be protected against contamination. Contaminated food shall be discarded immediately. This requirement was not met as evidenced by: LPA observed expired food in each chiild's
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Emergency bag. LPA also observed a non- working mini- refrigerator to have string cheeses, Go-Gurt, relish, lemonade, and mold inside, and accessible to children. This poses a potential health and safety risk to the children in care.
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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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 06/16/2021
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attending) in each room. At 9:31 a.m., LPA observed expired foods in the children's Emergency bags. LPA advised Director/Licensee to discard expired food items and replace. LPA observed the facility to have functioning carbon monoxide detectors in each room that meet the standards established in Chapter 8 of Part 2 of Division 12.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Director/Licensee states that disinfectants and cleaning compounds are stored in a latched cabinet under sink. Director/Licensee states that facility has no poisons currently. LPA advised Licensee to lock poisons with a combination or key lock and place in an inaccessible area.

All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. At 9:33 a.m., LPA observed an accessible mini refrigerator in Room 117 to have string cheeses, Go-Gurt, relish, lemonade, and mold. Pictures were taken. Per Licensee/Director, staff and children do not use the refrigerator, and the refrigerator has been turned off. LPA inspected food in the storage room, in classroom 117, to be in good quantity. At 9:40 a.m., LPA observed dry food (Goldfish and Cheezits) to be opened from their original containers and not sealed. Pictures were taken. All storage containers for solid waste, including moveable bins had tight-fitting covers and are kept on, and in good repair. LPA advised Licensee/Director that trash cans, used to discard food, should have tight fitting lids or solid waste bags shall be discarded immediately after each meal. LPA observed the floors to be clean and safe.

Outdoor playground equipment is in a safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. LPA advised Licensee to level ground surrounding playground, dirt areas. At 9:55 a.m., LPA observed an opening at the left end of the surrounding playground gate, which leads out to to an alleyway and busy side street. There are 2 pieces of wood barricading fence opening, and a 3-foot tall vinyl fencing blocking the wood pieces, leaving a 9 inch gap on one side of the wood pieces, and 7 inch gap on the other side of the wood pieces. Pictures were taken. LPA advised Licensee/Director to close the opening with 4 foot fencing. Per Licensee, there is

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 06/16/2021
NARRATIVE
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100% supervision at all times when children are playing outside. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. Availability of outdoor drinking water was observed. LPA observed the door leading out of the facility, to the alley, to have a door code on outside of door. Per Licensee, there is a Waiver that was granted to use the playground across the alley way. LPA observed doors leading out to another door that opens up into the alley. LPA advised Licensee to install a latch on the 2nd gate, leading out to the alley, making it inaccessible to children in care as a precautionary measure. There are no bodies of water or firearms on the premises. LPA advised Licensee to ensure staff to have 100% proper and visual supervision at all times.

FACILITY RECORDS:

All individuals present have obtained a criminal record clearance or criminal record exemption. LPA observed at least one person trained in CPR and Pediatric First Aid present during this inspection.

Children’s Records were reviewed for completeness; Inspection of required forms was made. In review of children’s records, files contain emergency information including, but not limited to the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary, along with physician's information and allergies.

LPA reviewed staff files, including Health Screenings, and Children's roster. Sign-In and Sign-Out sheets were reviewed. LPA advised staff to have child’s authorized representative sign their child(ren) in and out, and include a full signature and record the time of day. Children present were signed in. LPA observed each child’s file to contain a medical assessment. LPA observed all personnel to be in good health, and are physically and mentally capable of performing assigned tasks. LPA advised Director/Licensee that personnel, posing as a threat to the health and safety of children, shall be relieved of their duties. Disaster drill log was available, last drill was conducted on 1/21/2021. First Aid supplies were observed in all rooms.

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SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2021
Section Cited

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Buildings and Grounds: (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement was not met as evidenced by: Licensee did not secure fencing around outdoor
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play area. LPA observed an opening on left end side of the fencing, and 2 wood pieces barricading the opening, allowing for a 9 inch and 7 inch gap surrounding wood pieces. This poses a potential health and safety risk to the children in care.
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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: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405
VISIT DATE: 06/16/2021
NARRATIVE
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Per Licensee/Director, most current on-the-job training regarding housekeeping and sanitation principles dated 04/29/2021. LPA observed staff to have current Mandated Reporter Training (AB1207). LPA observed staff immunization records (i.e. Influenza, Measles, and Pertussis).

Menus are posted one month in advance where it is visible by the child's authorized representative. Per Licensee/Director, facility provides lunch and AM and PM snack. Per Licensee/Director, there are no children with medications at this time. Per Director/Licensee, medication is stored in a locked box in each room, and placed in a latched cabinet on a high shelf. Licensee/Director states, medication is only administered to a child when accompanied with doctor's instructions and medication form children's authorized representatives complete and sign before administering medication. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htmLPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA advised licensee of the Mandated Reporter Child Care Training that became in effect January 1, 2018, and to maintain a copy of the certificate on file for each staff. The training must be completed every 2 years.

The following deficiencies listed on the attached deficiencies 809D page are being cited in accordance with California Code of Regulations Title 22.

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 BHAGYA WIJEWARDANE Licensee/Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

End of report

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-8417
LICENSING EVALUATOR NAME: Alanna GontarekTELEPHONE: (323) 854-8644
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6