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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010138
Report Date: 08/17/2022
Date Signed: 08/17/2022 10:41:40 AM

Document Has Been Signed on 08/17/2022 10:41 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HOPPER CREEK MONTESSORIFACILITY NUMBER:
283010138
ADMINISTRATOR:ELIZABETH FOSTERFACILITY TYPE:
850
ADDRESS:2141 2ND STREETTELEPHONE:
(707) 231-8768
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 10DATE:
08/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Brenna Roth, LicenseeTIME COMPLETED:
10:55 AM
NARRATIVE
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LPA Kevin O'Connell made an unannounced Case Management- Deficiency visit/ inspection regarding an issue associated with a complaint investigation.
During the course of the investigation it was discovered that the Licensee does not have a fully developed Admission Agreement per regulation at the facility as required by Regulation 101219.
Admission agreements must specify Basic Services, Available optional services, payment provisions, including-Basic rates, optional service rates, payor, due date and frequency of payment.
Modification conditions, including the requirement that the child's authorized representative be given at least 30-calendar days written notice of any basic rate change, refund conditions and conditions under which the agreement may be terminated.

A Parent Handbook was available that did contain segments of the agreement but was not complete.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D.

A Notice of Site Visit must be posted for 30 days from today.


This report was read and reviewed with the Licensee
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Kevin O'Connell
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 08/17/2022 10:41 AM - It Cannot Be Edited


Created By: Kevin O'Connell On 08/17/2022 at 10:26 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOPPER CREEK MONTESSORI
FACILITY NUMBER: 283010138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited
CCR
101219

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Agreements (c)The licensee, or his/her designee, and the child's authorized representative shall sign and date the child's admission agreement no later than seven calendar days following admission.
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Licensee states that she will supply CCL with a new complete Admission Agreement by 8/31/22.
kevin.oconnell@dss.ca.gov
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This requirement is not met as evidenced by:
Based on record review and Licensee's admission, the licensee failed to include fully developed, signed admission agreements in the children's files per regulation. This poses a potential risk to the 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:Leslie Lepori
LICENSING EVALUATOR NAME:Kevin O'Connell
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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