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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566211104
Report Date: 07/17/2019
Date Signed: 07/17/2019 02:50:28 PM

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 SCHOOLFACILITY NUMBER:
566211104
ADMINISTRATOR:GRACE PEIRISFACILITY TYPE:
830
ADDRESS:1776 ERRINGER ROAD #104TELEPHONE:
(805) 584-7900
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:12CENSUS: 10DATE:
07/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Grace PeirisTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Francisco Pedroza made an unannounced inspection for the purpose of conducting an Annual/Random Inspection. LPA met with facility Administrator Grace Peiris and explained the purpose of the inspection. LPA and Administrator together toured the facility inside and out. The facility currently had 10 infants in care at the time of the inspection. The center operates from 7:00 AM to 6:00 PM, Monday thru Friday. This is a combined center with an Preschool program.

Licensing required notices were posted prominently on the wall at the entrance of the facility. There was three staff supervising the 10 infants in the classroom. The one classroom had age appropriate toys and furnishings. The classroom had a changing table with sink readily accessible. LPA observed seven cribs available for infants to use. Facility uses cots for older infants that do not use the cribs. Food and milk is stored in a refrigerator located in the classroom. LPA reviewed a sampling of Individual needs & services plans and feeding plans. Children bottles and food were properly labeled with child's name and date. LPA did not observe any toxins/hazardous items accessible to children. Administrator advised the center does not have firearms or ammunition at the facility. Continued on 809C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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 2
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: 566211104
VISIT DATE: 07/17/2019
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Center uses written sign-in/sign-out sheets located at the entrance of the building. A sampling of children and staff records were reviewed. Teachers have required qualifications. Teachers present have current First Aid/CPR certificates that expire on 02/22/2019. Teachers present have current AB 1207 Mandated Reporter Training certificates that expire on 01/09/2020. LPA verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. Director was provided a guide for Safe Sleep and effects of Lead Exposure brochures.

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

No deficiencies were cited during today's visit.



THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
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