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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566214333
Report Date: 09/15/2021
Date Signed: 09/15/2021 09:29:49 AM

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:MONTESSORI ONEFACILITY NUMBER:
566214333
ADMINISTRATOR:AMAL PELAWATTAFACILITY TYPE:
850
ADDRESS:620 TRIUNFO CANYON ROADTELEPHONE:
(805) 777-8833
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91361
CAPACITY:91CENSUS: 33DATE:
09/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Amal PelawattaTIME COMPLETED:
09:35 AM
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On September 15, 2021, at 8:35AM, Licensing Program Analyst (LPA) Betzayra Cervantes conducted an unannounced case management inspection to obtain signatures for the Complaint Investigation Report dated for 09/14/2021. LPA was unable to complete the report at the time of the inspection due to technical difficulties.

LPA met with Director Amal Pelawatta and the purpose of the inspection was discussed. Census was taken and ratio and capacity limitations of the license were found to be in compliance during today’s inspection.

Report was reviewed, signed, and a copy was provided to Director.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 consecutive daysduring the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Appeal Rights were explained & provided.

Exit interview was conducted with Director, Amal Pelawatta.
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra CervantesTELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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