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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405026
Report Date: 04/19/2023
Date Signed: 04/19/2023 04:24:23 PM

Document Has Been Signed on 04/19/2023 04:24 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:SPRINGFIELD MONTESSORI SCHOOLFACILITY NUMBER:
073405026
ADMINISTRATOR:SHASHI LALFACILITY TYPE:
850
ADDRESS:2780 MITCHELL DRIVETELEPHONE:
(925) 944-0626
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 226TOTAL ENROLLED CHILDREN: 226CENSUS: 53DATE:
04/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Tammie MeyerTIME COMPLETED:
04:45 PM
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On 4/19/23 Licensing Program Analyst (LPA) Monica Mathur met with Site Supervisor, Tammie Meyer to conduct a Case Management inspection for Lead Testing results at Springfield Montessori School.

It was indicated that there was one (1) water outlet which exceeded the Action Level established by the State for exposure. Facility submitted External Water Sampler Self-Certification Form (LIC 9275); Facility Sketch (LIC 999); Child Care Center Sampling Checklist Form (LIC 9276) and photos of remediated newly installed fixture.

Today on 4/19/23 LPA conducted an inspection and toured the premises with Director. Outlet located in Room 8, was in use for food prep and drinking water. LPA observed outlet has been replaced and new one installed. Re-testing is scheduled in May. Site Supervisor states outlet is currently not in use and alternate water source is provided.

Due to outlet being in use by children, they were exposed to lead which is a potential risk to health and safety of children in care. Deficiency is cited on page 809D. Citation was cleared today because facility has completed remediation process.

Exit interview conducted and report was reviewed with the Site Supervisor, Tammie Meyer. A NOTICE OF SITE VISIT was given and must remain posted for 30 days.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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 04/19/2023 04:24 PM - It Cannot Be Edited


Created By: Monica Mathur On 04/19/2023 at 04:06 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: SPRINGFIELD MONTESSORI SCHOOL
FACILITY NUMBER: 073405026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited

101700.3(b)(2)

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Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. This requirement is not met as evidenced by:
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Outlet has been replaced and new one installed. Post testing is scheduled in May 2023. Deficiency was cleared today and Letter of Clearance provided.
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Per inspection, there is 1 outlet with lead exceedance. Site Supervisor states outlet has been used for food prep and drinking water. This posed potential risk to health/safety of children.
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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023


LIC809 (FAS) - (06/04)
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