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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405005
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:21:53 PM

Document Has Been Signed on 11/20/2023 02:21 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:A LITTLE WORLD MONTESSORI ACADEMYFACILITY NUMBER:
073405005
ADMINISTRATOR:SAMUDRA DE ALWISFACILITY TYPE:
850
ADDRESS:355 PARKER AVETELEPHONE:
(510) 799-6361
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 34TOTAL ENROLLED CHILDREN: 34CENSUS: DATE:
11/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Samundra De Alwis TIME COMPLETED:
02:30 PM
NARRATIVE
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On 11/20/2023 at 10:30 AM Licensing Program Analyst (LPA), A. Curry conducted an unannounced visit to open a complaint at the facility. During today's visit, the LPA observed an uncleared adult, who volunteered 19 hours the previous week, volunteering/working at the facility. Violations of the California Code of Regulations, Title 22, Division 12, Section 101170 (e)(1)(2) is being cited on the attached LIC 809D.

The director is aware that all adults, who volunteer at the facility for over 16 hours per week, must obtain a criminal background clearance and volunteers are never allowed to alone with children in care. The director indicated she mailed the Transfer Request form to the Oakland Regional office.

The director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

A civil penalty of $100 will be assessed.

Exit interview conducted, appeal rights were given, and report is reviewed with the Director, Samundra De Alwis.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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 11/20/2023 02:21 PM - It Cannot Be Edited


Created By: Ashley Curry On 11/20/2023 at 12:07 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: A LITTLE WORLD MONTESSORI ACADEMY
FACILITY NUMBER: 073405005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2023
Section Cited
CCR
101170(e)(1)(2)

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101170Criminal Record Clearance(e) All individuals subject to a criminal record review..shall prior to working, residing or volunteering in a licensed facility(1) Obtain a California clearance or a criminal record exemption..(2)Request a transfer of a criminal record clearance...
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By 11/24/2023 will email livescan receipt for Michelle or associate previous clearance to the facility.

Check Guardian or contact the Oakland office to verify Michelle has eligible clearance.
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This requirement was met as evidence by:
Based on observation and interview the facility did not comply with the section cited above by ensuring volunteers obtain an eligible fingerprint clearance and/or associated to the facility,which poses a potential risk to health and safety to children in care.
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023


LIC809 (FAS) - (06/04)
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