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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198020782
Report Date: 08/12/2022
Date Signed: 08/12/2022 04:15:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Fabiola Vasquez
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20220811164632
FACILITY NAME:EVERGREEN MONTESSORI ACADEMY, LLCFACILITY NUMBER:
198020782
ADMINISTRATOR:ROSANGELICA GONZALEZFACILITY TYPE:
850
ADDRESS:2038 E. FOOTHILL BLVDTELEPHONE:
(626) 460-0468
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:52CENSUS: 31DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Catherine Sweet, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Day care child wandered from facility due to lack of supervision.
Staff are not providing a safe environment for day care children while in care.
INVESTIGATION FINDINGS:
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At 10:30 AM on 08/12/22 LPA Fabiola Vasquez conducted an unannounced 10- Day complaint inspection. LPA meet with Catherine Sweet, Executive Director (ED) who guided LPA on tour of the facility LPA observed in the Primary Preschool room 12 children with 02 staff in the Two year old room 14 children with 2 staff, in the Toddler component room 5 children with 1 staff. LPA explained the purpose of the visit is to investigate the above allegations. Total Census: 31 children with 5 staff

Throughout the course of the investigation, interviews were conducted with ED, Staff (S) S1, and Parking lot business owner. LPA obtained copies of Children Roster, Personnel Roster, LPAs observations, LPA took photos of the route that C1 walked through begging from the classroom to the back door through the play yard, to the back gate door and walkway, across the school parking lot onto the street side walk to the business parking lot area where C1 was found. At the time of the inspection, At 12:00 PM. LPA took measurements which is approximately 58 feet from the classroom to the parking lot where C1 was found.
PAGE 1 OF 3
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 33-CC-20220811164632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN MONTESSORI ACADEMY, LLC
FACILITY NUMBER: 198020782
VISIT DATE: 08/12/2022
NARRATIVE
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Pertaining to the allegation that “Day care child wandered from facility due to lack of supervision" .

Based on statements disclosed during interviews with ED, who stated the C1 was last observed inside the classroom at 11:45 AM. Another statement made by S1 that she found C1 in the business parking lot away from the facility at 11:56 AM. C1 was missing for 11 minutes. Another statement made by the business parking lot owner that C1 was standing alone near a couple and a lady walking on sidewalk called 911 (Police).

This agency has investigated the complaint alleging that “Day care child wandered from facility due to lack of supervision"

Based on the interviews, record review, photos taken, measurements obtained the preponderance of evidence standard has been met; therefore, the above allegation ifound to be substantiated. Title 22, California Code of Regulation, 101229 Responsibility for Providing Care and Supervision is being cited on the attached LIC 9099D page an LPA issued an immediate civil penalty (refer to Civil Penalty Assessment (LIC 421IM), dated 08/12/22 to the Licensee.

Pertaining to the allegation that “Staff are not providing a safe environment for day care children while in care".

Based on statements made by ED that S3 contacted her to inform that C1 had gone missing and they were looking for her everywhere. That S3 and S4 were convinced C1 was inside the building. LPA observed the route C1 used to exit the building LPA observed the back door in the yard and the parking lot gate to be accessible.

This agency has investigated the complaint alleging that “Staff are not providing a safe environment for day care children while in care"

Based on the interviews, record review, photos taken, measurements obtained the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Title 22
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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 33-CC-20220811164632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN MONTESSORI ACADEMY, LLC
FACILITY NUMBER: 198020782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2022
Section Cited
CCR
101216(e)(1)
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(1) No child(ren) shall be left without the supervision of a teacher at any time** 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.


This requirement was not met as evidenced by
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Safety teachers are required to take a safety head count every 15 minutes and logging it in pro care app. Staff have been trained where to stand from the entrty doors, cubby areas and bathrooms. Meeting on body position where to stand outside. Will bring a safety specialist to train all staf. Go over with staff on personal rights,
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C1 was last observed inside the classroom at 11:45 AM. S1 found C1 in the business parking lot away from t he facility at 11:56 AM. C1 was missing for 11 minutes.





This poses an immediate risk to the health and safety of children in care.
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supervision. In the form of a memo and aquire staff signitures. Submit to LPA by 8/15/22.
Type A
08/15/2022
Section Cited
CCR
101223(a)(2)
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Personal Rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.


This requirement was not met as evidenced by
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We brought the pasadena fire department to discuss or opitions on how to raise the handle and put a magnetic lock at the top of the gate. Locked all the back door added door bells. Replace the back gate leading to the parking lot. Want to put a latch higher so children can't reach.
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 S3 contacted ED to inform that C1 had gone missing and they were looking for her everywhere. That S3 and S4 were convinced C1 was inside the building. LPA observed the route C1 used to exit the building LPA observed the back door in the yard and the parking lot gate to be accessible to C1. This poses an immediate risk to the health and safety of children in care.
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Have contacted companies to come to the property and give us the option we can work with.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 33-CC-20220811164632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN MONTESSORI ACADEMY, LLC
FACILITY NUMBER: 198020782
VISIT DATE: 08/12/2022
NARRATIVE
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California Code of Regulation, 101223(a)(2) Personal Rights is being cited on the attached LIC 9099D page .
LIC 9224 ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS was provided.

A copy of this report must be provided to the authorized representative of all currently enrolled children and newly enrolled children for the next 12 months (1 year). The report shall be provided, no later than the next business day or the next day that the child is in care. The Acknowledgement of Receipt of Licensing Reports (LIC 9224) shall be signed and kept in each of the children’s records.

A Notice of Site Visit was provided to director.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Executive Director this report along with Appeal Rights (LIC 9058) were provided.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4