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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010138
Report Date: 02/15/2024
Date Signed: 03/05/2024 12:48:34 PM

Document Has Been Signed on 03/05/2024 12:48 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
SANTA ROSA RO, 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: 15DATE:
02/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:Brenna Roth TIME COMPLETED:
09:52 AM
NARRATIVE
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**This is an amended report to document that the administrator listed above left the facility on 04/29/2022 and did not work at the facility during the time of the incidents listed in this report.**
During the course of a complaint investigation, additional deficiencies were identified involving lack of supervision. Based on interviews conducted with staff, children, adults as well as LPA’s observations from 11/16/2023 through 01/25/2024 it was determined that children were unsupervised on multiple occasions while at the facility. More specifically that children are left alone in a room while in time out, as well as children being left alone in certain rooms of the facility. One child stated that they sit alone in a room when on time out. A3 stated their child sustained an injury when left alone in the bathroom, while A7 witnessed a child sitting alone at a table inside the facility when all other children and staff were outside. LPA also observed a child alone in the bathroom while the teachers and other children were outside. In addition, LPA observed two children alone unsupervised in the front room of the facility with both doors to the room closed. While the two children were in the room, one child was hitting and trying to bite the other child.

LPA requested the facility roster from the Licensee on multiple occasions which was not complete upon request. Not all currently enrolled children were on the facility roster, the roster was last updated 05/25/2022. During the investigation when the LPA was attempting to contact children’s authorized representatives, it was noted that the information on the facility roster was incorrect, which violates regulation.

In addition, while at the facility LPA verified children's records (C1-C7) were still incomplete which were first reviewed and incomplete on 01/29/2024 during an annual inspection and requested to be complete by 02/12/2024. A civil penalty is being assessed today.

Civil penalties are assessed on form LIC421FC for Failure to Correct, in the amount of $100 per violation per day, for a total amount of $300 assessed today.

The following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC809D. Appeal Rights were provided.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 02/15/2024 01:30 PM - It Cannot Be Edited


Created By: Melinda Mohr On 02/15/2024 at 11:15 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: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
101229(a)(1)

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101229(a)(1) (a)The licensee shall provide care and supervision as necessary to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Licensee and staff have received the handout "Active Supervision At-A-Glance" and will review together at a staff meeting. Licensee and staff will also complete the Active Supervision Toolkit. Licensee will email LPA Mohr proof of staff meeting minutes to Melinda.Mohr@dss.ca.gov
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 This requirement is not met as evidenced by:

Based on interviews and observations the facility is not providing supervision to children while in care, which poses a potential health, safety or personal rights risk to persons in care.

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Type B
02/29/2024
Section Cited
HSC1596.841

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1596.41 Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.
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Licensee will update facility roster and email to LPA Mohr @ Melinda.Mohr@dss.ca.gov
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This requirement is not met as evidenced by:

Based on record review, interviews and observations the roster was incomplete upon request. This poses a potential health, saftey or personal right risk to persons 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:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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