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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490101798
Report Date: 02/20/2020
Date Signed: 02/20/2020 12:05:36 PM

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: 78DATE:
02/20/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amanda MusteredTIME COMPLETED:
12:10 PM
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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 02/04/2020 incident in which at 12:15 p.m. a child (C1) fell on the playground and appeared to briefly lose consciousness. Staff immediately contacted the parents and provided first aid and monitoring to the child. Staff advised the parent (A1) to take C1 to the hospital for medical assessment. Staff later reported the parent did so and provided staff with documentation of medical assessment. At the time of the incident, five staff were providing care to 60 children on the playground. Facility reported the incident to CCLD by telephone and fax on 02/05/2020.

During today's inspection, LPA toured the facility, obtained facility documents, observed 13 teachers and additional support staff providing care and supervision to 78 children, and interviewed C2 and two staff (S1-S2). 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: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
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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