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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573603060
Report Date: 10/15/2021
Date Signed: 10/15/2021 04:03:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MONTESSORI COUNTRY DAY IIFACILITY NUMBER:
573603060
ADMINISTRATOR:DEBBIE ROBERTSONFACILITY TYPE:
830
ADDRESS:2802 SPAFFORDTELEPHONE:
(530) 753-5225
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:8CENSUS: 5DATE:
10/15/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Debbie RobertsonTIME COMPLETED:
03:40 PM
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On 10/15/2021 at 9:27am Licensing Program Analyst (LPA) Morgan Pringle met with Director Debbie Robertson for an Unannounced Annual Inspection. One (1) classroom was toured for a health and safety inspection. Five (5) infants and two (2) staff members were present during the inspection. The facility operates from 8:00am – 5:00pm.

The facility has age appropriate materials in the classroom that are observed to be clean and in good condition. The outdoor space has ample shade for the children and age appropriate materials. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All sinks and were observed to be clean and in proper working order. The counters were observed to be clean and free from hazards. The napping equipment and changing table is clean and properly stored in each room. All bottles and food are properly stored and labeled. All children have LIC9227 Individual Infant Sleeping Plan on file as well as a Needs and Services Plan. LPA did not observe any harmful or unattended bodies of water in or around the facility. Facility also does not currently have a working carbon monoxide detector (see LIC9102TV).

The facility is operating within its licensed capacity and is in ratio. All proper postings are made visible in the entry way of the facility. The fire/disaster drill log was complete with the last drill logged 9/7/2021. Due to the Covid-19 pandemic the facility has been using an electronic sign in/out. LPA informed Director about how to get a waiver. A physical census of the children and staff was taken and cross referenced with the sign-in and out log. All children are accounted for and properly signed in/out. Facility has a waiver for a centralized fingerprint. LPA obtained a sample of the children’s files and the staff files. During LPA’s record review it was observed to C1 was missing a completed Physicians Report and T1 did not have a proper criminal record clearance. Director removed T1 from the facility during the inspection. Staff member will not return until clearance is obtained. LPA cleared the deficiency during the inspection (see LIC809-D)..

Continued on 809-C

SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 340-6032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: MONTESSORI COUNTRY DAY II
FACILITY NUMBER: 573603060
VISIT DATE: 10/15/2021
NARRATIVE
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Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Personnel Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Director was reminded that California Law requires all facilities to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov. Director was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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 Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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.

Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Debbie Robertson.

SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 340-6032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: MONTESSORI COUNTRY DAY II
FACILITY NUMBER: 573603060
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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Director will ensure staff memebr obtains full criminal record clearance before returning to work. During visit, staff was sent home and told that they may not return until clearance is obtained. Deficiency was cleared today 10/15/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 340-6032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: MONTESSORI COUNTRY DAY II
FACILITY NUMBER: 573603060
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
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Dorector will ensure that child obtains completed physician report.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 340-6032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5