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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417551
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:07:46 PM

Document Has Been Signed on 08/10/2023 02:07 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
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PENINSULA MONTESSORI SCHOOLFACILITY NUMBER:
197417551
ADMINISTRATOR:KRIKORIAN, CLAUDIAFACILITY TYPE:
850
ADDRESS:907 KNOB HILLTELEPHONE:
(310) 544-3099
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90277
CAPACITY: 84TOTAL ENROLLED CHILDREN: 84CENSUS: 31DATE:
08/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:SHANE HICKSON, DIRECTORTIME COMPLETED:
02:15 PM
NARRATIVE
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On 08/10/2023, Licensing Program Analyst (LPA) Lisa Clayton conducted an unannounced case management visit to review children's files for compliance.

- LPA reviewed 8 of the 42 currently enrolled children files, and observed them to be non-compliant, due to missing LIC 9224 forms.

Per Admin. Theresa, the forms have not been distributed to the parents/authorized representatives as licensee is awaiting the Appeal Decision.

Based on LPA record review and Theresa's statement, deficiencies are being cited today.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulation and/or Health and Safety Code, deficiencies are cited: (see next page 809D).

An exit interview was conducted, a copy of this report, along with appeal rights were read provided to the Director. This report shall me made available to the public upon request. LIC 9213 Notice of Site Visit provided and required to be posted for 30 days.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 08/10/2023 02:07 PM - It Cannot Be Edited


Created By: Lisa Clayton On 08/10/2023 at 01:36 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PENINSULA MONTESSORI SCHOOL
FACILITY NUMBER: 197417551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
HSC
1596.8595(c)(1)

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1596.8595(c)(1)A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children....(1) of subdivision (a) of Section 1596.893b.
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Facility Administrator will provide parents with LIC 9224 Acknowledgement of receipt of LIcensing Reports and report by 08/11/2023 (school will be closed from 08/14 - 08/31/2023).
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This requirement is not met as evidenced by:
Based on LPA record review of 8 files for currently children enrolled and facility administrators statement that the LIC 9224 has not been given to the parents/authorized representstives.
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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:Karren Starks
LICENSING EVALUATOR NAME:Lisa Clayton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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