566211067-10-15-2024-17-CC-EBAY-DA3UVU-20241015155544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566211067
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:55:53 PM

Document Has Been Signed on 10/15/2024 03:55 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	SIMI VALLEY MONTESSORI SCHOOL		FACILITY NUMBER:	566211067
ADMINISTRATOR:	GRACE PEIRIS		FACILITY TYPE:	850
ADDRESS:	1776 ERRINGER ROAD # 104		TELEPHONE:	8055847900
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	48	CENSUS: 24	DATE:	10/15/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Grace Peiris		TIME COMPLETED:	01:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 10/15/24, at 12:45 PM, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced Three Year Required inspection of the abovementioned Child Care Center (CCC). LPA met with Grace Peiris, Director of the CCC. LPA explained the purpose and nature of the inspection. The CCC is a combination center with both a Preschool and Infant license. The Preschool operates Monday-Friday, 7:00 AM – 5:45 PM. The facility uses two classroom (Room 2, 2 years of age to 3.5 years of age, and Room 3, ages 3.5 years of age to 5 years of age) for child care services. At the time of inspection, LPA observed 24 children on site, along with three teachers (cleared and associated). The CCC's Director is assisting with the care and supervision of children on site. LPA notes 12 children were sleep at the time of the inspection.

LPA observed required licensing forms and documents posted on the walls of Room 3. LPA observed the CCC's Sign In/Out forms near the entry door of the classrooms. The forms contained the arrival and departure times of children in care and well as the signatures of the children's authorized representatives. The classrooms have age appropriate equipment and furnishings available to children in care. The CCC has a number of carbon monoxide detectors affixed to the walls. The detectors were not tested as children in care were in different phases of sleep.

The facility is orderly. The CCC uses two restrooms. All restrooms are in safe and sanitary operating condition. LPA observed a refrigerator on site which is capable of storing food for children in care. Lunches and snacks are provided by the parents of children in care. The CCC has supplemental food on site for children should the need arise. The CCC also has available (bottled) drinking water for children inside and outside of the facility. CCCs constructed before 1/1/20, to test their water (used for drinking and food preparation) for lead contamination before 1/1/23, and then every 5 years, except after the date of the first test. For CCC licenses issued after 7/1/22, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. (CONT. LIC 809-C, Page 2)

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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 4

Document Has Been Signed on 10/15/2024 03:55 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SIMI VALLEY MONTESSORI SCHOOL	FACILITY NUMBER: 566211067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238(g)

Buildings and Grounds

(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation/interview, the licensee did not comply with the section cited above in that a bottle of Windex cleaner was located in an unsecure cabinet under the sink, accessible to children in care, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Director to submit a plan to CCLD (elvin.baddley@dss.ca.gov) outlining how toxins will be inaccessible to children in care by the close of business (5:00 PM) on 10/29/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SIMI VALLEY MONTESSORI SCHOOL	FACILITY NUMBER: 566211067
	VISIT DATE: 10/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medication and sharps are observed in elevated locations at the CCC which are accessible to staff members but inaccessible to children in care. At 1:35 PM, LPA observed a bottle of Windex cleaner in an unsecured cabinet under a sink in the classroom. LPA reminded Director to ensure cleaning compounds and toxins are inaccessible to children in care.

The CCC outdoor playground areas are enclosed by wrought iron fencing and partitioned to separate an area of play for preschool and infants/toddlers. The fence’s entry/exit gates are secured. The surfaces of the outdoor playground areas are varied. LPA observed age appropriate play equipment in the play areas. The play equipment is free of sharp, loose or pointed objects. The play structures in the outdoor playground areas have adequate cushioning materials to absorb falls and shade created by building overhangs. LPA reminded Director to replace outdoor play equipment and furnishings when such items begin to degrade or are not in good repair. No bodies of water are observed on site.

LPA reviewed children, staff and facility records. The children’s records sampled were complete and found to contain emergency contact information and immunization records, among other required licensing documentation and forms. Staff records were reviewed. Staff records sampled were complete and found to contain First Aid/CPR certifications (EMSA approved) and Mandated Reporter Training certification, among other required licensing documentation and forms. LPA notes the last disaster drill at the facility occurred on 9/16/24. No firearms or ammunition are stored on site.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility representative was reminded that all adults 18 and over, including employees and volunteers,
as specified in HSC section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. (CONT. 809-C, Page 3)

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SIMI VALLEY MONTESSORI SCHOOL	FACILITY NUMBER: 566211067
	VISIT DATE: 10/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

A Type B Deficiency is being cited based on LPAs' observation/interviews/record reviews pursuant to Title 22 of the CA Code of Regulations (refer to LIC 809-D). Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Facility representative Grace Peiris.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4