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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415070
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:44:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CALAVERAS MONTESSORI SCHOOLFACILITY NUMBER:
434415070
ADMINISTRATOR:AMANDA WAGNERFACILITY TYPE:
850
ADDRESS:1331 E. CALAVERAS BOULEVARDTELEPHONE:
(408) 263-6330
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:36CENSUS: 31DATE:
06/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Yukha LamkhooTIME COMPLETED:
12:00 PM
NARRATIVE
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On Thursday, June 10, 2021 9:40 AM, Licensing Program Analyst (LPA) Manel Estoesta conducted a Case Management Visit following an Unusual Incident occurred on 06/02/2021. Unusual Incident reported via telephone by the Licensee Coleen Noll and LPA received LIC 624 on 06/04/2021.

LPA met with the Director Amanda Wagner and Director of Operations Yukha Lamkhoo. Present on this visit were 31 preschool children and 4 staff. The facility has an active Infant License number 434415069 on the same Facility Address.

LPA toured the facility. LPA conducted staff interview. LPA obtained copies of current LIC 500 and Children’s Roster. LPA reviewed records of the staff, child in care and "ouch reports".

Based on the Unusual Incident reported and interviews, lack of supervision is being cited. Penalties are being assessed for a zero tolerance.

Lack of supervision poses an immediate risk to children in care and is therefore a Type A deficiency, which must be corrected by the Plan Of Correction (POC) 06/17/2021. Due to the severity of this deficiency, $500.00 has been assessed today and $100.00 per day if not corrected by the POC 06/17/2021. Any violation of this serious nature within the next 12 months will be immediately a $1000.00 civil penalty and $100.00 per day until corrected.

See 809 C for continuation.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CALAVERAS MONTESSORI SCHOOL
FACILITY NUMBER: 434415070
VISIT DATE: 06/10/2021
NARRATIVE
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The Director of Operations acknowledges that upon receipt of a Type A deficiency, the Licensee shall post the LIC 809-D with the Type A deficiency for 30 days. Further, because a Type A deficiency was cited during this visit, the Licensee must provide a copy of this report to all parents, as well as newly enrolled parents, for the next 12 months. Additionally, form LIC 9224 (Acknowledgment of Receipt of Licensing Reports) must be signed by each existing parent and newly enrolled parent and a copy of that signed LIC 9224 form be placed in each child's file during the next 12 months.

An exit interview was conducted where the citation and plan of correction were discussed. Appeal rights were given and explained to the Director. Notice of Site Visit was posted.

The attached Civil Penalty Assessment - Immediate $500 was cited during this inspection. The appeals rights were provided. A copy of this report was also provided and is to be kept in the facility records for a period of three years.

A NOTICE OF SITE VISIT WAS PROVIDED. IT MUST BE POSTED NEAR THE FACILITY'S FRONT ENTRANCE AND MUST REMAIN POSTED FOR 30 DAYS.

LPA provided information guidance of the following web links;
https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/
https://ccld.childcarevideos.org/child-care-center-operators/what-is-a-civil-penalty/
https://ccld.childcarevideos.org/child-care-center-operators/supervising-children-in-child-care-centers/

End of Report.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: CALAVERAS MONTESSORI SCHOOL
FACILITY NUMBER: 434415070
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2021
Section Cited

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101229(a)(1) No (child)ren shall be left without the supervision, including visual supervision, of a teacher at any time......
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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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3