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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710472
Report Date: 11/16/2022
Date Signed: 11/16/2022 10:28:15 AM


Document Has Been Signed on 11/16/2022 10:28 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:RAINBOW MONTESSORI CHILD DEVELOPMENT CENTERFACILITY NUMBER:
430710472
ADMINISTRATOR:SIMA PANAHYFACILITY TYPE:
850
ADDRESS:790 DUANE AVENUETELEPHONE:
(408) 738-3261
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:378CENSUS: 185DATE:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sima PanahyTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Mel Matos met with Sima Panahy, Director, for an unannounced case management investigation. Purpose of today's investigation: investigate an Unusual Incident that the Facility self reported to the San Jose Child Care District Office on November 10, 2022.

The Unusual Incident occurred on Thursday November 10, 2022 at approximately 12:50 PM in Room H-4. Director states there were 16 napping preschool children with one teacher in Room H-4 at the time of the incident. Director states that the teacher observed one preschool child having a seizure on her napping cot. Director states that the teacher attempted to communicate with the child but the child was unresponsive. Director states that the teacher immediately called the front office to call 911, child's parents, and for staff assistance. Director states that she and Micki Rodenborn, HR manager, went to Room H-4 to assist the teacher. Director states that the child was breathing; however, the child was unresponsive to any voice commands from staff.

Director states that she was on the line with 911 and was given guidance on how to tend to the child before paramedics arrived at the Facility. Director states the child was kept on her side on the mat until paramedics arrived. Director states that paramedics arrived at the Facility within five minutes of the initial call. Sima states that the child's parents arrived at the Facility before the child was transported to Stanford Hospital via ambulance. Director states that the child was kept overnight at Stanford Hospital for observation and released the following day. Director states that the child is doing fine and has not had any additional seizures. Director states that the child is scheduled to return on Friday November 18, 2022. Director states that she and staff will also be meeting with the child's parents on Friday November 18, 2022 to get any update(s) on the child's condition.

Exit interview conducted and report was reviewed with Sima Panahy, Director. No deficiencies issued during today's investigation. A notice of site visit was given and must remain posted adjacent to the main door for 30 days
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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