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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417530
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:34:07 PM

Document Has Been Signed on 12/03/2024 04:34 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:MISSION VALLEY MONTESSORI CHILDREN'S LRNG. CENT.FACILITY NUMBER:
013417530
ADMINISTRATOR/
DIRECTOR:		LIBASTE, JUSTINFACILITY TYPE:
850
ADDRESS:39600 MISSION BLVD.TELEPHONE:
(510) 793-2327
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 199TOTAL ENROLLED CHILDREN: 199CENSUS: 121DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Justin LibasteTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On today's date, 12/03/2024, Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced on another matter. LPA met with Facility Representative, May Sampang. Director, Justin Libaste, arrived approximately an hour after LPA's arrival. Also present during today's visit were 27 additional staff members and 121 preschool aged children.

During LPA's inspection, LPA observed C1 being brought into the front doors by a parent of another child in care. Per Director, C1 was in the parking lot for approximately 15 minutes without visual supervision.

Based on the information received, a TYPE A deficiency is being cited on today's date, 12/3/2024 (see attached LIC809D).

LPA Otsuji informed Director, Justin Libaste, that this report dated 12/3/2024 document(s) one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Otsuji informed the facility representative to provide a copy of this licensing report dated 12/3/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An exit interview was conducted where the citation and plan of correction were discussed. Appeal rights were given and explained to the Director, Justin Libaste.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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Document Has Been Signed on 12/03/2024 04:34 PM - It Cannot Be Edited


Created By: Melanie Otsuji On 12/03/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MISSION VALLEY MONTESSORI CHILDREN'S LRNG. CENT.
FACILITY NUMBER: 013417530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement is not being met as evidence by:
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Director is to create a plan to ensure children remain visually supervised at all times. Plan is to include at a minumum training of all staff on supervision and include an operable auditory alarm system for all exit doors. Plan to be submitted no later than close of business 12/4/2024.
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 During LPA's inspection, LPA observed C1 being brought into the front doors by a parent of another child in care. Per Director, C1 was in the parking lot for approximately 15 minutes without visual supervision. This poses an immediate risk to the health, safety, or personal rights to persons in care.
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Training agenda topics and signatures of all staff in attendance to be submitted to LPA no later than close of business 12/20/2024.

$500 immediate civil penalty is being issued due to absence of supervision citation

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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:Wynn Norona
LICENSING EVALUATOR NAME:Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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