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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110778
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:36:39 PM


Document Has Been Signed on 11/03/2022 02:36 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:FAIRFIELD MONTESSORIFACILITY NUMBER:
480110778
ADMINISTRATOR:KRYSTEK & BAILEYFACILITY TYPE:
850
ADDRESS:1101 UTAH STREETTELEPHONE:
(707) 427-1442
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:30CENSUS: 17DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Center Directors Vicki and LorraineTIME COMPLETED:
02:45 PM
NARRATIVE
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An annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. The facility file was reviewed prior to this inspection. A review of the personnel report on 11/02/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. This program is privately operated.

The facility’s operating hours are 07:00AM- 06:00PM, Monday – Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children. Center Director stated poisons are not stored on the premises. The regulation that poisons are locked with a key or combination lock was reviewed. The facility was free of flies, insects and rodents. The toys, floors, desks and other equipment and surfaces were clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children both indoors with a water dispenser and outdoors with a water fountain. The children’s bathrooms were in safe and sanitary condition. Food prep areas are clean. Food is properly stored and free of contamination. Garbage cans containing solid waste did not have tight fitting lids, an advisory note was issued. The playground was free of hazards. The playground equipment and surface areas were in safe condition. There is pea gravel cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. The Center director stated no weapons are stored on site and none were observed. During today's inspection, staffing ratios were being met and there were 16 children were being supervised by one teachers and one aides. The facility was operating within the licensed capacity. At least one staff member present during the visit (S3) possessed current CPR and First Aid certifications. Continued on 809-C
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRFIELD MONTESSORI
FACILITY NUMBER: 480110778
VISIT DATE: 11/03/2022
NARRATIVE
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 Center director was not able to produce disaster drill log verify one drill with in the last six months, a deficiency was cited. 10 children’s records were reviewed at 09:49AM, and contained identification forms with authorized representative information. Six children were missing medical assessments, immunizations and blue CDPH 286 a deficiency was cited. Five children were missing their admissions agreement an advisory note was issued. Three staff records were reviewed at 12:25PM. S1 was missing health screening form, a deficiency was cited. All staff were missing AB 1207 Mandated Reporter training certificate an advisory note was issued. The sign in/out procedure was reviewed and in compliance.

Center 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Center Director Lorraine Krystek.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/03/2022 02:36 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: FAIRFIELD MONTESSORI
FACILITY NUMBER: 480110778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Last drill was conducted in April 2022. 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.
POC Due Date: 11/15/2022
Plan of Correction
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Center Director agreed to conduct a drill within two weeks and document it on the disaster drill log and email, mail, or fax the log to LPA Elpidia Hernandez Torres at: elpidia.hernandez-torres@dss.ca.gov, mail: 1450 Neotomas Ave Suite 100 Santa Rosa, CA 94505, and fax: 707-588-5099.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review staff member S1 did not have TB on file or LIC 503 Health screening report. the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Center Director will give LIC 503 to S1 and email, mail, or fax LIC 503 to LPA Elpidia Hernandez Torres at: elpidia.hernandez-torres@dss.ca.gov, mail: 1450 Neotomas Ave Suite 100 Santa Rosa, CA 94505, and fax: 707-588-5099.

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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 11/03/2022 02:36 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: FAIRFIELD MONTESSORI
FACILITY NUMBER: 480110778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, 10 Children's records C1,C3,C4,C6,C8,C10 were missing LIC 701 Physcians report and Immunizations records, and Blue CDPH 286. 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.
POC Due Date: 11/24/2022
Plan of Correction
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Center director stated they will send out notification to those guardians and will get the LIC 701 back by 11/24/2022 Center director will send in a document with each guardians signiture that they turned in LIC 701, and immunizations. To LPA Elpidia Hernandez Torres via email, mail or fax: elpidia.hernandez-torres@dss.ca.gov, mail: 1450 Neotomas Ave suite 100 Santa Rosa CA 95405, fax: (707) 588-5099.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7