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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370106
Report Date: 08/10/2021
Date Signed: 08/10/2021 02:52:29 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:HILLSIDE MONTESSORIFACILITY NUMBER:
304370106
ADMINISTRATOR:NADESAN, AJANTHAFACILITY TYPE:
830
ADDRESS:19900 EL TORO ROADTELEPHONE:
(949) 858-8818
CITY:SILVERADO CANYONSTATE: CAZIP CODE:
92676
CAPACITY:10CENSUS: 4DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:DirectorTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA),Mahnaz (Nancy) Malek conducted an on site inspection for the purpose of an Annual Required- 1 year. The Covid-19 Emergency Response questionnaire was reviewed and answered by the director, Ajantha Nadesan before entering the facility. LPA toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken. Due to Covid- 19 guidelines, LPA observed staff and children were following CDC and Dept of Public Health Guidelines. The overall census observed was 2 staff and 4 infants and toddlers in one room. The sleeping area was completely barricaded with a wall. The infants and toddlers were being supervised. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA provided Guardian Information and website infohttps://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian.
During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. AM Snack is provided by the facility and lunch is provided by the parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by using children's water bottles. The children's bathrooms are clean and sanitary. The crib area was inspected. The beddings are washed at the facility. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility. Staff files were reviewed for staff present during the facility inspection on this date. Two staff files were reviewed. Health screening and immunizations as required
Continued on page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: HILLSIDE MONTESSORI
FACILITY NUMBER: 304370106
VISIT DATE: 08/10/2021
NARRATIVE
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were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against pertussis, measles for staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. The staff had a current certificate on file. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications. Among 2 reviewed files, neither of them had current certificates, however according to director , a CPR and 1st aid course has been scheduled for all staff for this month. This deficiency was cited on LIC 809D.
The director was informed that the Criminal Record Statement (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. She was also informed that the LIC 508 must be submitted with all Criminal Background Clearance, and an ID card.
Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of (5) of children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day.
LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.htm
The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at
least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.
The director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov The facility has Continued on page 3
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: HILLSIDE MONTESSORI
FACILITY NUMBER: 304370106
VISIT DATE: 08/10/2021
NARRATIVE
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been added to email list to receive Quarterly Update from the Department.
Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The director was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative. A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility. English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a T-shirt and not be too hot or too cold. In the areas that were evaluated, the following deficiency was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. Please refer to LIC 809D. Section 101216(f)
An exit interview was completed with director. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. The director was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

Documents/Information to be updated and returned to the Licensing Office; Personnel Report (LIC 500), Emergency Disaster Plan (LIC 610), and Fire Drill Log

Report ends here.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HILLSIDE MONTESSORI
FACILITY NUMBER: 304370106
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited

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At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This section was not met as evidenced by reviewing 5 staffs' files. Four staff's CPR
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and 1st aid cards were expired on 3/5/21 however one staff's card from preschool program will expire on 8/21 but the staff person is not scheduled to be in the facility from opening to closing. The facility operates 7am to 6 pm and the staff with current CPR card works from 8 am to 5:30 pm. The director has scheduled a training for August 2021. This is 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4