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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444408900
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:42:58 PM


Document Has Been Signed on 03/30/2023 04:42 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:12CENSUS: 10DATE:
03/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joy Parker & Madelynn TershyTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Marilou Monico and Cortney Nelson, met with Site Director, Madelynn Tershy, and teacher, Joy Parker, for a Case Management Inspection. During today's inspection, LPAs observed infants were placed into sleep sacks during nap time. LPAs advised Joy and Madelynn that sleep sack is considered a swaddling device and will require an exception/waiver for the child/children to continue using it. LPAs observed infants who were unable to climb out the crib sleeping on wooden floor beds. LPAs observed an infant under 12 months of age napping with his body covered with blanket from shoulder to toe.
Deficiencies were cited on the following pages:

Exit interview conducted and report was reviewed with teacher, Joy Parker, and Site Director, Madelynn Tershy.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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


Document Has Been Signed on 03/30/2023 04:42 PM - 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 SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2023
Section Cited

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101439.1 Infant Care Center Sleeping Equipment - (b) A crib or portable-crib meeting United States Consumer Product Safety Commission safety standards shall be provided for each infant who is unable to climb out of a crib.
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The facility to submit a written plan to ensure that infants (who are unable to climb out the crib) are placed in cribs when napping. A written plan of correction to be sent to Licensing by 04/10/23.
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This requirement was not met as evidenced by:
LPAs observed infants who are unable to climb out a crib sleeping on wooden floor beds. This poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
04/10/2023
Section Cited

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101430 Infant Care Activities - (c) An infant shall not be swaddled while in care.

This requirement was not met as evidenced by:
LPAs observed infants were placed into sleep sacks during nap time. This poses a potential risk to the health, safety, and personal rights of children in are.
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The facility to cease using sleep sack or request a waiver for infants to use sleep sacks during nap time. Waiver to be sent to Licensing by 04/10/23.

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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/30/2023 04:42 PM - 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 SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2023
Section Cited

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101223 Personal Rights - (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidenced by:
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The facility to submit a written plan by 03/31/23 outlining what provisions should be made to meet Safe Sleep Regulations.
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LPAs observed an infant under 12 months of age covered with blanket from shoulder to toe during nap time. This poses an immediate risk to the health, safety, or personal rights of children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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