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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490101798
Report Date: 06/08/2022
Date Signed: 06/08/2022 01:36:15 PM


Document Has Been Signed on 06/08/2022 01:36 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:SPRING HILL MONTESSORIFACILITY NUMBER:
490101798
ADMINISTRATOR:HAMIDI, SHAHARAZADFACILITY TYPE:
850
ADDRESS:825 MIDDLEFIELD DRTELEPHONE:
(707) 763-9222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:107CENSUS: 90DATE:
06/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Shaharazad Hamidi, Loryn HattenTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst Jennifer Velasco (LPA) conducted an unannounced case management inspection while at the facility for another purpose. LPA met with Director Shaharad Hamidi (D1) and Operations Manager Loryn Hatten (D3), toured the facility, obtained facility documents, observed staff supervision of children, and conducted interviews. During today's inspection, 90 children received care from twelve classroom staff. Based on LPA's observations, review of facility documents, and witness statements, facility staff have been attempting to supervise children on the playground while also attempting to visually supervise, from outdoors and at a distance, children who were indoors using the bathroom. This "straddling"--attempting to supervise children in both an indoor and an outdoor area--constitutes a lack of supervision.
This report was discussed with D1 and D3. All licensing reports are public information and must be made available upon request for three years. The following violation(s) of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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 06/08/2022 01:36 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: SPRING HILL MONTESSORI
FACILITY NUMBER: 490101798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited

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No child(ren) shall be left without the supervision of a teacher at any time ... Supervision shall include visual observation. This requirement was not met as evidenced by: LPA's observation and multiple witness statements that multiple times staff attempted to supervise children on the
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playground and supervise from a distance as children used the indoor bathroom, resulting in a lack of supervision. This posed a potential health, safety or personal rights risk to persons in care.
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indoor and outdoor supervision at the same time. Director reported she will provide LPA with detailed documentation of staff training and sign-in sheets via email on or before POC date of 06/24/2022.
jennifer.velasco@dss.ca.gov

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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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