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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600679
Report Date: 05/24/2021
Date Signed: 05/24/2021 12:10:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MONTESSORI HOUSE OF CHILDRENFACILITY NUMBER:
300600679
ADMINISTRATOR:GUNAWARDENA, MAUREENFACILITY TYPE:
850
ADDRESS:1239 SOUTH MAGNOLIATELEPHONE:
(714) 761-3109
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:26CENSUS: 4DATE:
05/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Director/Owner Shirani PereraTIME COMPLETED:
11:45 AM
NARRATIVE
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The purpose of this visit was to obtain signatures and delivery of an amended Case Management Report and correction of Civil Penalty Assessment (LIC421FC) dated 12/09/2019, 01/10/2020 and 02/07/2020. Amended reports to correct the civil penalties issued for $1000 in error on 12/09/19, 01/10/2020 and 02/07/2020 . The correct civil penalty amount for each is $250. LPA's provided Director with paper Civil Penalty Assessments (LIC 421FC).

Licensing Program Analyst (LPA) Barajas and Nelson met with Director/Owner Shirani Perera. LPA toured the facility inside and outside. Census was taken. There was a total of 4 School Age children with 1 staff Maureen Gunawardena.

A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Director Shirani Perera was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above. LPA advised Director copy of appeal rights provided is also for amended paper Civil Penalties issued (LIC 421FC) on today's date.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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