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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 283010096
Report Date: 10/17/2024
Date Signed: 10/17/2024 02:24:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Melinda Mohr
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20241014090615
FACILITY NAME:NATURE'S WAY MONTESSORIFACILITY NUMBER:
283010096
ADMINISTRATOR:SARAH KIRKPATRICKFACILITY TYPE:
830
ADDRESS:3051 BROWNS VALLEY ROADTELEPHONE:
(707) 226-5437
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:36CENSUS: 29DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Mikali Rinehart TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not utilizing changing tables to change infant diapers.
Facility is operating out of ratio.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mindy Mohr made an unannounced complaint investigation visit today and met with Director Monica MacDonald (D1) and Site Supervisor (S1) Mikali Rinehart. LPA met with D1 to initiate the investigation by discussing the purpose of the visit. LPA Mohr also conducted interviews with the Director (D1), Site Supervisor (S1) and six staff (S2 – S7).

D1 confirmed children have had their diapers changed while out on the play yard. Staff interviews cooberated D1’s statement in which children have had their diapers changed while on the play yard, specifically children in the Magnolia classroom. D1 stated staff are aware they cannot change children’s diapers on the play yard and has spoken with each staff member regarding this. LPA observed two changing tables in the infant classrooms along with an additional changing pad for diaper changing use.

(Continued on LIC9099)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 01-CC-20241014090615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NATURE'S WAY MONTESSORI
FACILITY NUMBER: 283010096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2024
Section Cited
CCR
101428
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(d) When changing an infant's diapers, the following shall apply:
(1) Each infant shall be diapered on a changing table

This requirement is not met as evidenced by:
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Site Supervisor (s1) stated they have an all staff meeting on Nov. 1 and this will be discussed in detail. S1 will send LPA M. Mohr a statement that all staff will comply with diaper changing regulations to melinda.mohr@dss.ca.gov
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Based on interviews with staff it was confirmed that children have had their diapers changed while outside in the play yard.
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Type B
10/18/2024
Section Cited
CCR
101416.5
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(b) There shall be a ratio of one teacher for every four infants in attendance.


This requirement is not met as evidenced by:
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Site Supervisor stated they do have walkie talkies and will make sure they are used to request another teacher if a staff needs to use the restroom, grab snack ,etc.
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Based on interviews it was revealed that the facility has operated out of ratio on multiple occassions.
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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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20241014090615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NATURE'S WAY MONTESSORI
FACILITY NUMBER: 283010096
VISIT DATE: 10/17/2024
NARRATIVE
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In addition, staff interviews confirm the facility has operated out of ratio on multiple occasions, but only for a few minutes at a time. S2 and S4 stated an example would be a teacher leaving the classroom to get snack, while S6 stated a teacher will leave the classroom to use the restroom.

Therefore, based on the investigation, the preponderance of evidence standard has been met and the above allegations are found to be substantiated. The following violations of the California Code of Regulations, Title 22; Division 12: see LIC 9099D. Appeal rights were provided.

Exit interview was conducted, and report reviewed with Site Supervisor Mikali Rinehart.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3