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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216042
Report Date: 01/22/2021
Date Signed: 01/22/2021 04:54:31 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 - WEST VALLEYFACILITY NUMBER:
566216042
ADMINISTRATOR:ROSHINI WIREKOONFACILITY TYPE:
830
ADDRESS:15 MCCOY PLACETELEPHONE:
(818) 667-5205
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:12CENSUS: 0DATE:
01/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Roshini WirekoonTIME COMPLETED:
02:59 PM
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This is a change of location Pre licensing, previous facility number 566211840.

On January 22, 2021, at 1:34 PM Licensing Program Analyst (LPA) Francisco Pedroza conducted an announced tele-inspection for the purpose of completing a pre licensing inspection. Due to COVID-19 and the Department of Public Health guidelines, LPA conducted the tele-inspection via Facetime. LPA met with Administrator Wirekoon and explained the nature and the purpose of the inspection. Administrator Wirekoon provided LPA a tour of the facility inside and out. This is a combined center with a Preschool component. There were no children in care a the time of the inspection.

The center is shares the premises with another company. The center has their own access doors that require a pass code preventing unauthorized individuals from entering the center. Facility received an approved fire clearance from the Ventura County Fire Department on 01/21/2021. The facility will be using one classroom for children in care and have another room for isolation for illness. LPA observed licensing required notices posted prominently in the office. The classroom had age appropriate toys and furnishings. LPA observed one sink with a changing table within one arm reach readily accessible. LPA observed cribs for infants and cots available for the older infants that do not use cribs. Food and milk will be stored in refrigerator located in the classroom. LPA advised Administrator to ensure the food and milk is appropriately labeled with the child's name and date. LPA advised Administrator to ensure every infant has an updated needs and services plan for care. LPA did not observe any toxins/hazardous items accessible to children in care.

Continued on 809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
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 - WEST VALLEY
FACILITY NUMBER: 566216042
VISIT DATE: 01/22/2021
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The children have their own outdoor playground enclosed by a fence separated from the Preschool playground. The outdoor playground has age appropriate toys and furniture available for children. The playground has an ample amount of shade available. The center has water available for infants inside and out.

Facility Measurements:
Indoor 502 Square Feet meets the requirement for 11 infants.
Outdoor 841 Square Feet meets the requirement for 11 infants.

The center meets Title 22 Division 12 requirements.

License will be effective today, January 22, 2021 for 11 infants.

A copy of this report was reviewed and provided Administrator Wirekoon. Administrator agreed to receive a copy of report via email and voiced understanding that the read receipt confirmation from email will be in lieu of her signature once she receives the report. LPA requested Administrator send a signed copy of the report to licensing for records.

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: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC809 (FAS) - (06/04)
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