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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018405
Report Date: 08/23/2022
Date Signed: 08/23/2022 12:59:14 PM


Document Has Been Signed on 08/23/2022 12:59 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: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:
08/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Bhagya Wijewardane, Owner DirectorTIME COMPLETED:
09:45 AM
NARRATIVE
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08/23/22 Licensing Program Analyst (LPA) Fabiola Vasquez conducted a Case Management Deficiencies Inspection to address deficiencies observed during today’s inspection.

Upon arrival LPA meet with Katrina Torrez, Teacher in room 112 who was supervising 13 children at 8:45 AM., One child arrived, at 9:00 AM., second child arrive, at 9:04 AM., third child arrived at 9:05 AM., Staff # 2 (S2) arrived at 9:02 AM., LPA observed S2 stepped out of the classroom leaving Ms Torres with 16 children. Owner director Bhagya Wijewardane. arrived at 9:15 AM.

LPA observed 13 children being supervised by Teacher Ms. Torres. Three additional children arrived. Total children being supervised by one teacher was 16 children.

The following deficiencies on the attached LIC 809 deficiencies page is being cited in accordance with CA code of Regulations Title 22. 101216.3 Teacher-Child Ratio.

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). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224) 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 conducted with owner director Bhagya Wijewardane, during which appeal rights were given and explained. A copy of the Appeal Rights was provided. END OF REPORT
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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 08/23/2022 12:59 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: KEYSTONE MONTESSORI PRESCHOOL
FACILITY NUMBER: 198018405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited

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(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

This requirement was not met as evidenced by:
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Upon arrival LPA observed 13 children being supervised by Teacher Ms. Torres. Three additional children arrived. Total children being supervised by one teacher was 16 children.

This poses an immediate risk to the health and safety of 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) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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