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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371166
Report Date: 05/04/2020
Date Signed: 05/06/2020 09:56:16 AM

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 SCHOOL OF SAN CLEMENTE, LLCFACILITY NUMBER:
304371166
ADMINISTRATOR:ROUSH, JAIMEE LYNNFACILITY TYPE:
830
ADDRESS:1141 PUERTA DEL SOLTELEPHONE:
(949) 276-4160
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:40CENSUS: 4DATE:
05/04/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Catherine RobertsTIME COMPLETED:
10:00 AM
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An unannounced Case Management Legal/Non-compliance inspection was conducted on this date by Regional Manager Bertha Manzanares for the purpose of serving the following orders.

· Order to Licensee/Facility of Immediate Exclusion from Facility
· Order to Individual of Immediate Exclusion from all Facilities: Sara Esmeralda Amaya

During today’s inspection RM, Manzanares observed (4) Infants with (2) Teachers.

The Director was informed that effective today 05/04/20 Ms. Amaya must remain out of the facility and may not have contact with clients in, any child care facility or any other community care facility licensed by California Department of Social Services.

Exit interview was conducted. Appeal rights provided and explained
SUPERVISOR'S NAME: Maria HendrixTELEPHONE: (323) 981-3878
LICENSING EVALUATOR NAME: Bertha ManzanaresTELEPHONE: (714) 703-2805
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2020
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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