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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843031
Report Date: 06/30/2021
Date Signed: 06/30/2021 02:12:48 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: 64DATE:
06/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Acting Director Deseree Jones and Nel Jayawardana OwnerTIME COMPLETED:
02:30 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 on 06/18/2021 and was self reported by telephone on 06/17/2021. LPA toured 3 preschool rooms and observed 19 children in the Daffodil room with 2 staff, 33 children in the Cherry Blossom room with 3 staff, and 12 children in the Buttercup room with 1 staff. Written documentation and documents were provided. The following information was reported: On 06/16/2021, it was reported to management that during half day dismissal S1 (noted on LIC811) was observed physically restricting C1 (noted on LIC811) to sit with S1. S1 was holding C1 by the upper right bicep, which caused a bruise on the upper inside of the arm. Management viewed school footage showing the incident occurred and observed the bruise.
Based on the information gathered, the following violation has been identified: 101223 Personal Rights.
(a) The licensee shall ensure that each child is accorded the following personal rights:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation,
ridicule, coercion, threat, mental abuse or other actions of a punitive nature.

See LIC 809 D 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: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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: 06/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2021
Section Cited

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Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation,
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intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature. This requirement was not met as evidence by: It was observed that S1 physically restricting C1 by the upper right bicep, which caused a bruise. The is an immediate Health and Safety risk to children.
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diciplinary actions.

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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: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2021
LIC809 (FAS) - (06/04)
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