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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700790
Report Date: 04/21/2022
Date Signed: 04/21/2022 05:34:13 PM


Document Has Been Signed on 04/21/2022 05:34 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:LEGACY MONTESSORI SCHOOLFACILITY NUMBER:
376700790
ADMINISTRATOR:KATIE TSENGFACILITY TYPE:
850
ADDRESS:12310 NINTH STREETTELEPHONE:
(858) 679-9949
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:108CENSUS: DATE:
04/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Katie TsengTIME COMPLETED:
05:45 PM
NARRATIVE
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On 4/21/2022 at 11:15AM, Licensing Program Analysts (LPA) Patrick Ma and Licensing Program Manager (LPM) Renesha Pack conducted an unannounced case management inspection for the purpose of following up on an incident that was reported on 3/18/22 of an inappropriate interaction between children. LPA and LPM toured the facility indoors and playground. At the time of inspection, there were 69 children with 9 staff in 4 classrooms. Facility was within ratio and capacity.

Staff and children were interviewed today. Based on interviews and observations it was determined that there were blind spots on the playground that were not properly being supervised which resulted in the inappropriate interaction.

LPA Ma informed facility representative Katie Tsang that this report dated 4/21/22 documents 2 Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care. See LIC 809D for citations.

Also, LPA Ma informed the facility representative Katie Tsang to provide a copy of this licensing report dated 4/21/22 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An exit interview was conducted with the director and appeal rights (LIC 9058 1/16) were discussed. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA’s observed the director post notice of site visit.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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Document Has Been Signed on 04/21/2022 05:34 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: LEGACY MONTESSORI SCHOOL
FACILITY NUMBER: 376700790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited

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101216.3(b)(1) Teacher-Child Ratio. A ratio of one fully qualified teacher... and one aide for every 18 children in attendance in a preschool program is allowed when the aide meets the qualifications... This requirement was not met as evidenced by:
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Based on interviews and records reviewed facility has been caring for 24 children at the end of the day with 1 fully qualified teacher and 1 aid. This posed an immediate health and safety risk to children in care.
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Deficiency cleared during visit. LPA verified Staff #2 stayed until they were down to 18 children leaving one fully qualified teacher and aide, facility was within ratio.
Type A
04/21/2022
Section Cited

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101229(a)(1) Responsibility for Providing Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time...shall include visual observation. This requirement was not met as evidenced by:
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Based on LPA's interviews and observations the facility staff failed to ensure visual supervision of blind spots on the playground resulting in an inappropriate interaction between children. This poses an immediate health and safety risk to children in care.
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Director stated, she will also have all staff write a summary of the training they received, what they think supervision policy is, and how they plan to implement proper supervision. The written statements are due by 5/6/2022.
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: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/21/2022 05:34 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: LEGACY MONTESSORI SCHOOL
FACILITY NUMBER: 376700790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited

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101170(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department: This requirement was not met as evidenced by:
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Based on interviews and records review
Staff #2 was fingerprint cleared but not associated to the facilty. This poses an potential health and safety risk to children in care.
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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: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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