434408018-5-24-2022-07-CC-JGSS-CEQPLB-20220524112427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408018
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:24:43 AM

Document Has Been Signed on 05/24/2022 11:24 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:	MONTESSORI ACADEMY OF CAMPBELL		FACILITY NUMBER:	434408018
ADMINISTRATOR:	SVETLANA, AMIR		FACILITY TYPE:	850
ADDRESS:	177 EAST RINCON AVENUE		TELEPHONE:	(408) 378-9244
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	49	CENSUS: 44	DATE:	05/24/2022
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Christina Kougiouris		TIME COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analyst (LPA), James Santos arrived at the facility today for the continuation of the annual inspection. LPA met with Director, Svetlana Amir.

LPA reviewed children's and staff files. Children's records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, Physician's Report and Immunization Record. Staff records reviewed include Criminal Record Clearance, Statement Acknowledging Requirement to report Child Abuse, Immunization Record, CPR/First Aid, Mandated Reported Training, Qualifications and Education. Per review of facility record, the center conducts emergency disaster drills monthly.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA advised Director to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

Continued on next page

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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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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: MONTESSORI ACADEMY OF CAMPBELL	FACILITY NUMBER: 434408018
	VISIT DATE: 05/24/2022

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/24/2022)

As a result of this inspection, a deficiency has been cited. See LIC809D for deficiency. Appeal rights were reviewed and provided.

Exit interview conducted and report was reviewed with the Director. LPA advised Director of the required "mandated reporter" training for Assembly Bill, AB 1207 requirement for Child Care Providers that all staff must complete and renew every two (2) years. The website for the online training is: http://www.mandatedreporterca.com

A notice of site visit was given 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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2022 11:24 AM - It Cannot Be Edited

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: MONTESSORI ACADEMY OF CAMPBELL	FACILITY NUMBER: 434408018
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Two (2) staff records reviewed showed their Mandated Reporter Training certifications have expired.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Licensee stated they will complete the mandated reporter training for AB 1207 and submit proof of completion of training to CCL by POC due date of 6/24/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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