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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490101798
Report Date: 11/20/2019
Date Signed: 11/20/2019 09:45:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:SPRING HILL MONTESSORIFACILITY NUMBER:
490101798
ADMINISTRATOR:HAMIDI, SHAHARAZADFACILITY TYPE:
850
ADDRESS:825 MIDDLEFIELD DRTELEPHONE:
(707) 763-9222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:107CENSUS: 73DATE:
11/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Shaharazad HamidiTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Jennifer Velasco conducted an unannounced case management inspection re: an Unusual Incident Report (UIR) filed by Office Coordinator and Registrar Amanda Mustered (S3) about an 11/04/2019 incident in which at 3:20 p.m. a child (C1) in care was standing on the edge of a wooden planter and reaching for a leaf on the tree planted therein when she fell and scraped her right leg below the knee. Staff (S1) witnessed the fall and provided first aid promptly. S1 then notified another staff (S2), who called C1's authorized representative (A1) to pick up C1. A1 picked up C1 at 3:30 p.m. and provided additional first aid at home. A1 took C1 for medical assessment the following day, and C1 was determined not to have suffered significant injury. At the time of the incident, two staff (S1, S2) were providing care to eight children (C1-C8) on the playground. Facility reported the incident to CCLD by telephone on 11/05/2019 and by fax on 11/08/2019.

During today's inspection, LPA toured the facility, obtained facility documents, interviewed C1 and A1, met with director Shaharazad Hamidi (D1), and observed 12 teachers and additional support staff providing care and supervision to 73 children. No deficiencies were cited during this inspection.

Notice of Site Visit to be posted for 30 days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2019
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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