430710472-4-8-2021-07-CC-MSMS-BZVPUY-20210408113818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430710472
Report Date: 04/08/2021
Date Signed: 04/08/2021 11:39:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	RAINBOW MONTESSORI CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	430710472
ADMINISTRATOR:	SPYROULA RODENBORN		FACILITY TYPE:	850
ADDRESS:	790 DUANE AVENUE		TELEPHONE:	(408) 738-3261
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94086
CAPACITY:	378	CENSUS: 142	DATE:	04/08/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Dave Rodenborn & Sandra Kiss		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mel Matos conducted an announced tele-inspection via FaceTime with Operations Director, Dave Rodenborn, and Human Resources Director, Sandra Kiss. Purpose of today's tele-inspection: unusual incident that the Facility self reported to the Department on April 2, 2021. The Unusual Incident occurred at approximately 5:42 PM on Thursday April 1, 2021 per Dave Rodenborn. Dave states that a preschool child from Room G2 left the Facility with the wrong parent. Dave states that the staff from Room G2 assumed that the child had been signed out via the iPad system used by the Facility in each individual classroom. Dave states that the child followed her classmate and her classmate's parent through the front entry of the Facility. Dave states that the temperature screener, who was stationed at the front entry gate, noticed that the child was not with the correct parent and proceeded to follow the child to the parking lot. Dave states that the temperature screener caught up to the child near the front exit gate to the parking lot and brought the child back to the Facility. Dave states that the two staff in Room G2 were issued warnings and states that the Facility has implemented a policy in which at least one staff will be stationed by the entry to each classroom to ensure that children are signed out and released to the correct parent/authorized representative.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: RAINBOW MONTESSORI CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430710472
	VISIT DATE: 04/08/2021

NARRATIVE

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A “Type B” deficiency is being cited based on interviews conducted and record reviews in accordance with the California Code of Regulations, Title 22 (see LIC 809-D).

An exit interview was conducted and a Plan of Correction was reviewed and developed with Dave and Sandra. A copy of this report and appeal rights was discussed with the Dave and Sandra. LPA advised Dave and Sandra that this Complaint Investigation Report (LIC 9099) will be emailed to the Facility (dave@rainbow-montessori.com & sandra@rainbow-montessori.com). A reply to the email within 24 hours will serve as acknowledgement that the report was received.

A Notice of Site Visit will also be forwarded to Dave and Sandra, via email and will be required to be posted near the entrance to the Facility for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: RAINBOW MONTESSORI CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 430710472
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/09/2021 Section Cited	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision: he licensee shall provide care and supervision as necessary to meet the children's needs. 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.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: a preschool child from Room G2 left the Facility with the wrong parent on April 1, 2021. A staff person recognized the child and proceeded to follow and get the child back to the Facility. This poses a potential risk to the health and safety to children in care.	8 9 10 11 12 13 14	Dave and Sandra agreed to provide copies of the implemented policy and copies of sign in/sign out for Friday April 1, 2021 by Friday April 9, 2021.
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	1 2 3 4 5 6 7

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: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC809 (FAS) - (06/04)

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