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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406208351
Report Date: 09/09/2021
Date Signed: 09/09/2021 01:33:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CHILDREN'S ACADEMY MONTESSORI SCHOOL, THEFACILITY NUMBER:
406208351
ADMINISTRATOR:TAMERA DAVISFACILITY TYPE:
850
ADDRESS:711 ROLLING HILLS DRIVETELEPHONE:
(805) 239-9790
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:40CENSUS: 20DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Tamera DavisTIME COMPLETED:
01:40 PM
NARRATIVE
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On 9/9/2021 at 9:23am, Licensing Program Analyst (LPA) Melissa Stewart arrived at the child care center to conduct an unannounced, Case Management inspection and met with Director, Tamera Davis. LPA conducted a Risk Assessment for COVID19 and all answers indicated no exposure to COVID19. LPA explained the purpose of the inspection. There were two staff (S1 and S2) supervising 20 children in the preschool classroom. Director wore a face mask. S1 and S2 wore face shields without face covering. All 20 children wore child sized face shields without face covering.

On 9/8/2021 at approximately 4:30pm, Director called the Community Care Licensing Office and reported an incident which had occurred at the center earlier that same day. Per written report (LIC 624) Director explained that on 9/8/2021 at 11:50am, C1 rang the bell for lunch and that as the preschool children (ages 3-5 years) were lining up to come inside, C1 ran toward the line, tripped on C1s own feet and fell extremely hard directly on C1s left knee and then collapsed crying. S1 and S2 were outside supervising 19 children at the time of the incident.

S1 witnessed C1 fall and tended to C1. S1 observed that C1 could not stand and needed medical attention. S1 called for assistance of Director who took over the care of C1 and carried C1 inside the preschool classroom and applied an ice pack. C1s parents were called. Director spoke with P1 who asked Director to drive C1 to Twin Cities Emergency Room (ER) as both parents were more than an hours drive away from the center. Director reported that she agreed to transport C1 to the hospital because the injury was non-life threatening, with no open wounds, visible hemorrhaging or bruising. Director suspected that C1s knee had been dislocated. Director and C1 arrived at the ER at 12:20pm and C1 was admitted at 12:45pm. P1 arrived at 1:15pm and P2 arrived at 2:10pm.

Today, Director, S1, S2 and four (4) children were interviewed. C1 was not available for interview as C1 is still at the hospital. LPA left a voice message requesting a return call from the parent(s) of C1. Cont. on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CHILDREN'S ACADEMY MONTESSORI SCHOOL, THE
FACILITY NUMBER: 406208351
VISIT DATE: 09/09/2021
NARRATIVE
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Due to insufficient information available at this time, the incident requires further investigation.

LPA discussed current California Department of Public Health (CDPH) Guidance for Child Care Providers and Programs which states that Child care providers must ensure compliance with the current CDPH Guidance for the Use of Masks. As of 6/15/2021, the use of mask face coverings is required by CDPH and the Division of Occupational Safety and Health (CAL/OSHA) in child care indoor settings regardless of vaccination status. Children aged two and older should be taught and reminded to wear face coverings. LPA observed that staff and children were wearing face shields, but no attempt was being made to teach and remind children to wear face coverings as required.



Non-compliance with the current CDPH guidance for face coverings was was previously addressed with Director during an inspection on 6/7/2021 during which a Technical Assistance Advisory note was given. On 7/2/2021, the current guidance was addressed in an email conversation between LPA Stewart and Director. The Guidance for Child Care Providers and Programs dated 6/29/2021 was attached to the email via pdf document. Today, LPA provided a copy of PIN 21-18-CCP and Guidance for Child Care Providers and Programs dated 6/29/2021. LPA provided one box of 50 adult sized surgical masks to Licensee.

Type A deficiency cited today in accordance with the California Code of Regulations Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, Tamera Davis, whose signature on this form confirm receipt of these documents.

Upon receipt, provide copies of this licensing report to each parent/guardian of enrolled children and to parents/guardians of newly enrolled children during the next 12 months. Acknowledgement of Receipt LIC 9224 form shall be used for this purpose. LIC 9224 after completed shall be maintained in each child's file. (LIC 9224 was provided to Licensee).

LPA provided a Notice of Site Visit (LIC 9213) to be posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY

This report has been amended to remove the Civil Penalty cited in error. Amendment approved by Licensing Program Manager (LPM) Maria Mueller on 9/14/2021.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: CHILDREN'S ACADEMY MONTESSORI SCHOOL, THE
FACILITY NUMBER: 406208351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited

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Health and Safety Code Section 1596.885- (1) "The department may...suspend or revoke any license... upon any of the following grounds and in the manner provided in this act: (c) Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility... This requirement is not met as evidenced by:
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On 9/9/21, Director did not ensure the personal rights of persons in care to safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that children over the age of 2 years and facility staff (S1 and S2) did not wear face coverings while inside the facility, as
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 required by the CDPH Guidance effective 6/15/21, and an individual mask exception did not apply. A Technical Assitance Adisory note was given on 6/7/2021 and an email on 7/2/21 which included the 6/29/2021 CDPH guidance was previously provided to Director.
This report has been amended to remove the Civil Penalty cited in error. Amendment approved by Licensing Program Manager (LPM) Maria Mueller on 9/14/2021.

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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 MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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