566211104-2-21-2020-17-CC-FPEA-BLZU3F-20200221141329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566211104
Report Date: 02/21/2020
Date Signed: 02/21/2020 02:13:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 13	DATE:	02/21/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Roshini Wirekoon		TIME COMPLETED:	12:10 PM

NARRATIVE

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On February 21, 2020 at approximately 10:20 AM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with facility Administrator Roshini Wirekoon and advised her the purpose and nature of the inspection. LPA and Administrator toured the facility inside and out. There were 13 children 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 a Preschool program.

Licensing required notices were posted prominently on the wall at the entrance of the facility. The facility uses one classroom with a divider in the center for the infant program. One side of the classroom is where the younger infants are supervised, and the other side has the toddler children. Each classroom has 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 toddlers that do not use the cribs. Food and milk are stored in a refrigerator located in the office. Children bottles and food were properly labeled with child's name and date. LPA reviewed a sampling of Individual needs & services plans and feeding plans. LPA did not observe any toxins/hazardous items accessible to children. Administrator advised the center does not have firearms or ammunition at the facility.

At approximately 10:39 AM, LPA observed five infants and one toddler were being supervised by one teacher. LPA observed there was another teacher located on the other side of the partition. The other seven children in the toddler room were outside in the recreation yard with two teachers. LPA informed the Administrator that they were out of ratio because the second teacher was not on the side of the where the infants were being supervised. LPA was advised that the other teacher was preparing the other classroom for the toddlers return from the yard. Once the toddlers returned back to the classroom, the one toddler that was with the younger infants was transitioned to the toddler section. The following CCR, Title 22, Division 12 regulation was cited: 101416.5(b) Staff-Infant Ratio.

Continued on 809-C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2020

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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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: 02/21/2020

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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 Pediatric First Aid/CPR cards that expire on 2/22/2021. Teachers present have current AB 1207 Mandated Reporter Training certificates that expire on 10/30/2021. 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

A closing interview was conducted with Administrator. Appeal rights were provided and explained to licensee. Upon receipt, Licensee shall provide copies of this licensing report to parents/guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. The Acknowledgement of Receipt (LIC 9224) to parents shall be completed and signed by each parent/guardian with copies maintained in each child's file. Licensee was given a copy of LIC 9224 Acknowledgement of Receipt of Licensing Reports.

One Type A deficiency was 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 Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2020

LIC809 (FAS) - (06/04)

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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/06/2020 Section Cited	1 2 3 4 5 6 7	101416.5 - Staff-Infant Ratio (b) There shall be a ratio of one teacher for every four infants in attendance. This requirement was not met evidence by:
	8 9 10 11 12 13 14	Based on LPA's observations, LPA observed there was one teacher supervising five infants and one toddler. There was a second teacher on the other side of the partioned classroom not supervising children. This poses an immediate Health and Safety risk to persons in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7

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: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2020

LIC809 (FAS) - (06/04)

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