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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444408900
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:32:10 PM

Document Has Been Signed on 10/27/2022 03:32 PM - 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 SCOTTS VALLEY, INC.FACILITY NUMBER:
444408900
ADMINISTRATOR:TERSHY, MADELYNNFACILITY TYPE:
830
ADDRESS:123 SOUTH NAVARRA DRIVETELEPHONE:
(831) 439-9313
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Madelynn TershyTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, accompanied Building Official, Robin Woodman, and Contract Building Inspector, Steve Davis, for a walk through of the facility. Upon arrival, LPA was admitted into the facility by Assistant Director, Jasmine, and shortly after the inspection commenced, Site Director, Madelynn Tershy, arrived.

The facility currently has three (3) expired permits that do not have final inspector sign-off for the construction completed. LPA joined Robin and Steve for walk through to review facility building permits.

During the building inspection, Robin and Steve toured outside of the facility. A wooden pergola located in the infant yard was observed to be structurally unsound and was caution taped off during todays inspection. Steve states the pergola should be removed immediately and that children should not be allowed near the structure. Steve further advised that all structures should have footings/brackets installed to properly secure to the ground as the pergola today was not secured.

Further review of the facility permits is ongoing.

Exit interview conducted and report was reviewed with the Site Director, Madelynn Tershy.

As a result of today’s inspection, a deficiency was cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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Document Has Been Signed on 10/27/2022 03:32 PM - It Cannot Be Edited


Created By: Cortney Nelson On 10/27/2022 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited

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101238 Buildings and Grounds (a) The child care center shall be clean, safe, sanitary, and in good repair at all times to ensure the safety and well-being of children, employees, and visitors.

This requirement was not met as evidenced by:
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A wooden pergola, located in the infant yard, was observed to be structurally unsafe and was caution taped off by buildings inspector which poses an immediate risk to the health, safety, and personal rights of children in care.
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Per Site Director, the pergola will be removed on 10/29/2022 and pictures will be submitted.

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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
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