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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393617535
Report Date: 06/07/2019
Date Signed: 06/07/2019 11:16:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MONTESSORI SCHOOL OF MOUNTAIN HOUSEFACILITY NUMBER:
393617535
ADMINISTRATOR:MORENO, TERESAFACILITY TYPE:
850
ADDRESS:685 NORTH MONTEBELLO STREETTELEPHONE:
(209) 836-7459
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY:96CENSUS: 34DATE:
06/07/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Danish WinstonTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Ponce met with director Danish Winston for a Case Management- Incident inspection. The facility self reported an incident where there were inappropriate acts between two children while in the bathroom. There was a lack of supervision which is an immediate risk to the health and safety of children in care. The licensee Pamela Rigg has requested a glass wall be installed in the facility to allow for a better view in to the bathroom while children are present. The director stated that until the school district makes a decision, they will purchase and install a divider to allow for the children to have privacy without compromising supervision. Director also stated that they will continue to have one staff member posted near the bathrooms to ensure direct supervision, and the staff will communicate with one another as to avoid the staff observing the bathroom to have to assist the other children in the classroom while a child is using the bathroom.

Title 22 deficiency has been cited on the subsequent pages of this report.
director acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days 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. The LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee (LIC 9224 was provided).

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: MONTESSORI SCHOOL OF MOUNTAIN HOUSE
FACILITY NUMBER: 393617535
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2019
Section Cited
CCR
101229(a)(1)
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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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POC: Director provided a meeting agenda from May 31st regarding supervision. Director also provided LPA with a copy of the request to add a glass wall to allow for supervision. Therefore this
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This regulation was not met due to one child engaging in an inappropriate act with another child while in the bathroom when a staff member left to assist another child
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deficiency has been cleared.
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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: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC809 (FAS) - (06/04)
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