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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393617535
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:52:12 PM


Document Has Been Signed on 09/29/2022 02:52 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:MONTESSORI SCHOOL OF MOUNTAIN HOUSEFACILITY NUMBER:
393617535
ADMINISTRATOR:ELENES, DAISYFACILITY TYPE:
850
ADDRESS:685 NORTH MONTEBELLO STREETTELEPHONE:
(209) 836-7459
CITY:MOUNTAIN HOUSESTATE: CAZIP CODE:
95391
CAPACITY:96CENSUS: 52DATE:
09/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Daisy Elenes TIME COMPLETED:
03:15 PM
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On September 29, 2022 at 1:35 PM, Licensing Program Analyst (LPA) Stacey Williams conducted a case management inspection at the facility. LPA met with Facility Representative. LPA observed (52) fifty two children supervised by (9) nine staff in four classrooms. Criminal record clearances have been verified.

Community Care Licensing received an incident report on September 28, 2022 which outlined an incident involving a child (C1) needing medical attention. LPA discussed the incident with the Director. C1's file was also reviewed.

No Title 22 deficiencies were observed.

Exit interview conducted and report was reviewed with the Facility Representative, Daisy Elenes. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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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