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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380501318
Report Date: 01/20/2023
Date Signed: 01/20/2023 04:40:48 PM


Document Has Been Signed on 01/20/2023 04:40 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MONTESSORI HOUSE OF CHILDRENFACILITY NUMBER:
380501318
ADMINISTRATOR:DIANA GUSTAFSONFACILITY TYPE:
850
ADDRESS:1187 FRANKLIN STREETTELEPHONE:
(415) 441-7691
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:110CENSUS: 36DATE:
01/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Angie ZulagaTIME COMPLETED:
04:50 PM
NARRATIVE
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On 1/20/23 at 2:30PM, Licensing Program Analyst (LPA) Nathan Garcia arrived at the facility to conduct a closing complaint investigation and for a Case Management visit. Director, Yasha Nasiripour was not present but was contacted and available through a phone call during the visit. LPA spoke with the Administrative assistant, Angie Zulaga. Present during the inspection were 36 children and 7 staff members.

Purpose of the visit is due to a self reported unusual incident that involves staff member allegedly violating a child's Personal Rights that occurred on 1/11/23. Per director and staff members, a parent witnessed the teacher repeatedly yelling at the child and threatened to withhold food if the student did not comply. Per director, he heard the teacher from his office across the play area and into the classroom. The same parent also sent an email to the director regarding the incident.

Based on LPA's interview with the director, and evidence provided, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations,101223(a) is being cited on the attached LIC 809D. The center conducted an internal investigation and concluded to terminate the teacher involved in this incident on 1/12/23.
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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 01/20/2023 04:40 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MONTESSORI HOUSE OF CHILDREN
FACILITY NUMBER: 380501318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited

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Personal Rights CCR 101223(a)

This requirement is not met as evidenced by:
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Facility self reported the incident to the department and conducted an internal investigation and determined to terminate the staff. Director also needs to conduct trainings regarding staff and children's personal rights.
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Based on the LPA's interview conducted with the director, a staff violated a child's personal rights by repeatedly yelling and threatened to withhold food. Which poses/posed a potential health, safety or personal rights risk to persons 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: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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