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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700138
Report Date: 03/22/2023
Date Signed: 03/22/2023 12:35:47 PM


Document Has Been Signed on 03/22/2023 12:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:CARMEL VALLEY MONTESSORI SCHOOLFACILITY NUMBER:
376700138
ADMINISTRATOR:HOLLY ROSAFACILITY TYPE:
850
ADDRESS:3800A MYKONOS LANETELEPHONE:
(858) 720-2181
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:94CENSUS: DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:TIME COMPLETED:
12:45 PM
NARRATIVE
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On March 22, 2023 at 8:45 a.m. Licensing Program Analyst (LPA) Leilani Curtis visited the facility to conduct an annual inspection. Upon arrival LPA met with Assistant Director Stephanie Piceno-Prado and proceeded to tour the facility. LPA provided the LIC 125, Entrance Checklist to Ms. Piceno-Prado. Also present were 71 children with 9 staff members. Appropriate ratios and capacity were observed. Staff members have the required background clearances and are associated to the facility. No excluded individuals are present. The center director, Holly Rosa arrived at approximately 9:20 a.m. Furniture and age appropriate equipment is in good condition indoors and outdoors. Children's toilets and hand washing facilities are sanitary. Rooms are safe and clean. Food preparation area is clean, food and beverages are stored in covered containers at 45 degrees F or less if required, and storage containers for solid waste are covered. Drinking water is readily accessible inside and outside the classroom. All disinfectants, cleaning solutions, and other hazardous items are inaccessible to children through latches and locks. Storage area for poisons is locked. Medications are kept in a safe place inaccessible to children. The outdoor play area is fenced. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The areas around or under high climbing equipment, swings, slides, and similar equipment is cushioned with material that absorbs a fall. LPA observed approximately 5.75 inches of standing water in the sand box and another 2 inches of standing water beneath the climbing structure. The director states that the daycare children will not use these areas until the water has been removed/pumped out. The director will have the children use a separate area of the playground. LPA reminded Director that 100% visual supervision must be maintained when on the playground as the standing water is a safety hazard. The outdoor play area has a “pop up tent” used for shade. There are no other bodies of water or weapons at this facility. Fire drills are being conducted every 6 months. There is an operational carbon monoxide detector at the facility. First Aid/CPR certifications were reviewed and are in compliance.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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 6


Document Has Been Signed on 03/22/2023 12:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108


FACILITY NAME: CARMEL VALLEY MONTESSORI SCHOOL
FACILITY NUMBER: 376700138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 children's files reviewed did not contain a signed admission agreement. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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The director states that she will send LPA a copy of the signed admission agreements for C2 & C5 via email by 3/30/23.
Type B
Section Cited
CCR
101226(e)(3)(A)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Two daycare children have expired medication (Epi-Pens) at the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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The director states that she will send the expired Epi-Pens home with the parent/guardian of C3 & C5 and request new medication. The director also states that she will send LPA a signed and dated statement detailing how she will ensure that expired medication is not maintained at the facility via email by 3/30/23.
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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CARMEL VALLEY MONTESSORI SCHOOL
FACILITY NUMBER: 376700138
VISIT DATE: 03/22/2023
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This facility provides Incidental Medical Services – IMS. 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.

Admission agreement, emergency information and medical assessment forms were reviewed for some children. Two children have expired Epi-Pens at the facility and two children files reviewed do not contain admission agreements. Sign in/sign out sheets are well maintained. Staff records contain documentation of education, training, and/or experience. Menus are posted. LPA obtained an updated Emergency Disaster Plan for Child Care Centers- LIC610A, Parent Handbook, Personnel Report-LIC500 and Children’s Roster-LIC9040. The director states that they no longer operate a toddler option. The last time the toddler option was operational was in the year 2020. The director will submit an updated application to have the toddler option removed from the license. The director will also submit an updated Administrative Organization-LIC 309 by 4/22/23.

See LIC809D for cited deficiencies.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Director Rosa was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Rosa.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Grace CurtisTELEPHONE: (619) 767-2235
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6