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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364844654
Report Date: 09/28/2021
Date Signed: 09/30/2021 11:35:24 AM

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:WHIZ KIDS MONTESSORIFACILITY NUMBER:
364844654
ADMINISTRATOR:CHAMARTY,KATYAINIFACILITY TYPE:
850
ADDRESS:14260 CHINO HILLS PKWYTELEPHONE:
(909) 450-7187
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:24CENSUS: 12DATE:
09/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Katyaini ChamartyTIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kim Leung conducted a case management visit at the facility this date on 9/28/2021 in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 9/17/2021. It indicates that on 9/3/2021, a child fell from the climber on the playground and sustained a fractured elbow.

Upon arrival, LPA met with facility director Kathy Chamarty and stated the purpose of the visit. Facility records were reviewed and interviews were conducted. A video footage was reviewed during inspection. LPA obtained information that on 9/3/2021 during outdoor activity time, Child 1 fell from the spider climber while hanging onto the one of the horizontal bars of the climber. LPA obtained information that the child fell from approximately one foot above ground and injured the left arm as well as received scratches in the face. LPA obtained information that staff applied ice pack to the child's arm and notified the parent after incident. Records revealed that the child was picked up by parent at 5:58pm and was taken to the doctor. Director Kathy Chamarty stated that on Sunday 9/5/2021, a message was left on the facility app by the parent notifying facility that the child went to the emergency room and was diagnosed a fracture on the elbow.

During the inspection, LPA toured the playground and observed that the fall zone of the spider climber did not have sufficient cushioning material to absorb falls. LPA observed a thin layer of rubber barks underneath and around the spider climber with hard-packed dirt exposing in several spots of the fall zone.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Kim LeungTELEPHONE: (951) 529-4713
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: WHIZ KIDS MONTESSORI
FACILITY NUMBER: 364844654
VISIT DATE: 09/28/2021
NARRATIVE
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Based on the information gathered and the inspection of the playground, the facility had failed to provide sufficient cushioning material to absorb falls. The incident occurred on Friday 9/3/2021. The director admitted that they had knowledge on 9/5/2021 or 9/6/2021 that the child went to the doctor for examination and was diagnosed a fractured elbow from the incident. However, facility failed to report the incident to Community Care Licensing until 9/17/2021.

See LIC809D for deficiencies cited per California Code of Regulations, Title 22, Division 12.

An exit interview was conducted with director Kathy Chamarty. A Notice of Site visit was issued and must be posted for 30 days. Director was provided with a copy of the appeal rights (LIC9058 12/2015) and her signature on this report acknowledges receipt of those rights. A copy of this report was provided to the facility. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

A copy of this report must be made available to the public, at the facility site, for 3 years.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Kim LeungTELEPHONE: (951) 529-4713
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WHIZ KIDS MONTESSORI
FACILITY NUMBER: 364844654
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2021
Section Cited

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Outdoor Activity Space. As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls. This requirement was not met as evidenced by: LPA observed that the fall zone of the spider climber did not
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have sufficient cushioning material to absorb falls. LPA observed a thin layer of rubber barks underneath and around the spider climber with hard-packed dirt exposing in several spots of the fall zone. A child fell from the spider climber on 9/3/2021 and received fractured elbow.
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made. A written statement with staff signatures and pictures will be submitted by 9/29/2021 on temporarily preventing access to the spider climber. Pictures and purchase receipt of additional cushioning material will be submitted by 10/4/2021.

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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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Kim LeungTELEPHONE: (951) 529-4713
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: WHIZ KIDS MONTESSORI
FACILITY NUMBER: 364844654
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2021
Section Cited

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Reporting Requirements. Upon the occurrence...any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours...(B) Any injury to any child that requires medical treatment...This requirement was not met as evidenced by:
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A child fell from the climber on 9/3/2021. The director admitted that they had knowledge on 9/5/2021 or 9/6/2021 that the child went to the doctor and was diagnosed a fractured elbow from the incident. Facility failed to report the incident to Community Care Licensing until 9/17/2021.
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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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Kim LeungTELEPHONE: (951) 529-4713
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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