566211104-10-15-2024-17-CC-EBAY-DA3UX2-20241015155736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566211104
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:57:43 PM

Document Has Been Signed on 10/15/2024 03:57 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:	566211104
ADMINISTRATOR:	GRACE PEIRIS		FACILITY TYPE:	830
ADDRESS:	1776 ERRINGER ROAD #104		TELEPHONE:	(805) 584-7900
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	12	CENSUS: 9	DATE:	10/15/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Grace Peiris		TIME COMPLETED:	04:15 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 1:46 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 Infant program has a Toddler Option and operates Monday-Friday, 7:00 AM – 5:45 PM. The facility uses one classroom (Room 1, which is partitioned to separate the Infants age children from Toddler aged children) for child care services. At the time of inspection, LPA observed 9 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 all children were in different phases of sleep at the time of the inspection.

LPA observed required licensing forms and documents posted on the walls. LPA observed the CCC's Sign In/Out forms near the entry door of the classroom. The forms contained the arrival and departure times of children in care and well as the signatures of the children's authorized representatives. The classroom has age appropriate equipment and furnishings available to children in care. As noted classroom is partitioned to separate the Infants age children from Toddler aged children. The classroom has ample cribs and mats for children in care with various levels of mobility. LPA also observed changing tables, one of which was in arm's length to a sink. The CCC has a carbon monoxide detector affixed to the wall. The detector were not tested as children in care were in different phases of sleep.

The facility is orderly. The CCC uses one restroom. The restrooms is in safe and sanitary operating condition. LPA observed a refrigerator on site containing children's food. The food was labeled and dated. The CCC 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 (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 3

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: 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

accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Medication, cleaning compounds and sharps are observed in elevated locations at the CCC which are accessible to staff members but inaccessible to children in care.

The CCC outdoor playground areas are enclosed by wrought iron fencing. The playground area is 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, sleep log checks, sleep plans 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. LIC 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: 2 of 3

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: 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 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: 3 of 3