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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018405
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:19:51 PM


Document Has Been Signed on 09/15/2022 04:19 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: 14DATE:
09/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Bhagya Wijewardane, Owner Director TIME COMPLETED:
04:30 PM
NARRATIVE
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On 9/15/22 LPA's Fabiola Vasquez and Enjoli Mayweather conducted an unannounced case management to address deficiencies obtained during a visit conducted on 9/15/22. LPAs met with Bhagya Wijewardane, Owner Director. Census: 14 children with 3 staff.

During an interview with the director, statements were made that parent of C1 and C2 informed that the children had blisters inside their and on the hands. Director failed to self report to the department. The following deficiencies on the attached LIC 809 deficiencies page is being cited in accordance with CA code of Regulations Title 22.

Exit interview was conducted with Bhagya Wijewardane, Owner Director, Report and Appeal Rights were explained and provided.

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.


END OF REPORT
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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 09/15/2022 04:19 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: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited

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Reporting Requirements: Report shall be made to the Department by telephone or fax within the Department's next working*** In addition, a written report containing th information.

This requirement was not met as evidenced by
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During an interview with the director, statements were made that parent of C1 and C2 informed that the children had blisters inside their and on the hands. Director failed to self report to the department.
This poses a potential 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: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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