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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843031
Report Date: 06/07/2021
Date Signed: 06/07/2021 09:13:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:ST. MARY'S MONTESSORI SCHOOL - FONTANAFACILITY NUMBER:
364843031
ADMINISTRATOR:CYNTHIA DAVILAFACILITY TYPE:
850
ADDRESS:7370 W. LIBERTY PARKWAYTELEPHONE:
(909) 200-4747
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:129CENSUS: 25DATE:
06/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:30 PM
MET WITH:Acting Director Deseree Jones, Director of Rancho Emily Turner, Nel Jayawardana OwnerTIME COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Diana Brasel arrived on the above noted date and time to conduct a case management visit. The visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 06/03/2021 and self reported by telephone on 06/02/2021. Documents were gathered and interviews were conducted. The following information was reported:
S1 and S2 (noted on LIC811) split the Daffodil class in half to nap in separate classrooms. S1 took a group of children to the Cherry Blossom classroom. S2 took a group of children to the Buttercup classroom. S1 returned to the Daffodil classroom after taking her children to nap and finds C1 (noted on LIC811) in the Daffodil classroom. C1 was accounted in S2's group but was left behind in the Daffodil classroom. This resulted in C1 being unsupervised for approximately 4 minutes.
Based on the information gathered, the following violations have been identified: 101229 (a)(1) Responsibility for Providing Care and Supervision.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

An exit interview was conducted.
A Notice of site visit was issued and shall be posted for 30 days. A copy of the appeal rights LIC 9058 was provided along with this report.

A copy of this report must be available to the public for three years.

LPA provided a copy of a completed LIC 9224 to be provided to parents of children enrolled.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Diana BraselTELEPHONE: 951-782-4952
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: ST. MARY'S MONTESSORI SCHOOL - FONTANA
FACILITY NUMBER: 364843031
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2021
Section Cited

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Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2 (e)(1) and 101230(c)(1). Super-
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vision shall include visual observation. This requirement was not met as evidence by: Staff admitted to leaving a child without direct supervison for approximately 4 minutes. This poses an potential health and safety risk to the children in care.
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of business day, 06/08/2021. The sign in sheets shall be submitted as the trainings are completed, per acting Director.

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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: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Diana BraselTELEPHONE: 951-782-4952
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021
LIC809 (FAS) - (06/04)
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