334846059-9-12-2022-09-CC-JGIE-CJ7S4Z-20220912133334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 334846059
Report Date: 09/12/2022
Date Signed: 09/12/2022 01:33:47 PM

Document Has Been Signed on 09/12/2022 01:33 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	COUNTRYSIDE MONTESSORI ACADEMY		FACILITY NUMBER:	334846059
ADMINISTRATOR:	JAFFERY, KANEEZ		FACILITY TYPE:	850
ADDRESS:	2266 GRIFFIN WAY		TELEPHONE:	(951) 340-2821
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY: 78	TOTAL ENROLLED CHILDREN: 55	CENSUS: 37	DATE:	09/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Kaneez Jaffery		TIME COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/12/2022 at time listed above Licensing Program Analyst (LPA) Justin Giese arrived at the facility to conduct a 1 year required annual inspection. LPA was granted entry by Director Kaneez Jaffery. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Normal days and hours of operation are: Monday- Friday, 6:30am - 6:00pm A review of the staff records and review of a sampling of children's records were conducted as part of this evaluation. The inspection consisted of reviews of the following domains: · Food Service · Reporting Requirements · Physical Plant · Care and Supervision · Children Records · Staff Records · Staffing Ratio and Capacity · Personal Rights The facility was found to be in compliance except where noted on LIC809D, DEFICIENCIES & PLANS OF CORRECTIONS

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY	FACILITY NUMBER: 334846059
	VISIT DATE: 09/12/2022

NARRATIVE

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Licensee was asked to updated the following if applicable:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization
5. LIC 308 Designation of Administrative Responsibility

· The following items have been posted and are updated where necessary:
License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
Parent’s Rights Poster (PUB393), Personal Rights (LIC613A); Child Car Seat Law, Menu

· The facility is operating within the terms of the license
· Ratios were met during this inspection
· Appropriate supervision was provided during this inspection
· Classrooms are equipped with age appropriate furniture and equipment in good condition
· Classrooms are clean and free of hazards
· No weapons stored at the facility
· There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Medications are stored where inaccessible to children: Locked boxes in Kitchen
· Hazards are stored where inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
· Poisons and toxins are locked: in closet in kitchen
· All floors shall be clean and safe
· Bathrooms were observed to be safe, sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Food preparation area is clean, free of litter, rubbish and free of rodents and other vermin

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY	FACILITY NUMBER: 334846059
	VISIT DATE: 09/12/2022

NARRATIVE

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Measures are taken to keep the facility free of flies, other insects and rodents
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins-have tight-fitting covers and in good repair
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request
· Uncontaminated drinking water shall be readily available both indoors and out and provided by Public water supply. Water pitchers and cups are used for indoor and outdoor play
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall: Rubber flooring
· Sign in/Sign out record was reviewed and meets regulation requirements
· A Staff member is present with current Pediatric CPR/First Aid which expires on 03/2023
· Opening and closing staff member’s CPR/First Aid expires on 03/2023
· Director completed Health and Safety Training and is on file, completion date 07/18/2021
· Staff qualifications were reviewed – health screening is on file and all staff meet educational requirements and health requirements for performing assigned tasks: See LIC809D
· Staff have received on the job training for house keeping, sanitation and universal health precautions
Licensee was informed of the Department has inspection authority per Health and Safety Codes sections: 1596.852, 1596.853 and 1596.8535.

Licensee was informed of Unusual Incident Reporting email
UnusualIncidentReportsDO09@dss.ca.gov

· Required records for children shall ensure that each child’s record contain a medical assessment and contain the Identification and Emergency Information

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY	FACILITY NUMBER: 334846059
	VISIT DATE: 09/12/2022

NARRATIVE

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· Documentation of fire & earthquake drills to be conducted every six months: Last drill on 09/12/2022

Reminders:
· AB2370 – Lead Exposure, day care facilities, effective January 1, 2019. The bill requires that all Child Care Centers, operating in a building constructed before January 1, 2010, shall have their drinking water tested for excessive lead levels, on or after January 1, 2020, but no later than January 1, 2023. Child Care Centers must thereafter test their drinking water every five years after the date of the initial test.

· AB605 – Child day care facilities, birth to school-age license; Effective January 1, 2021. It requires the California Department of Social Services, in consultation with stakeholders, to adopt regulations on or before January 1, 2021, to create a Child Care Center license to serve infant, toddler, preschool, and school-age children. It also requires, before January 1, 2024, that all Child Care Centers transition to one-center licenses. Access to forms & Regulations for Child Care Centers online at www.ccld.ca.gov.

LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm For CCCs: Incidental Medical Services (IMS) policy was discussed

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY	FACILITY NUMBER: 334846059
	VISIT DATE: 09/12/2022

NARRATIVE

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Facility representative was reminded that all adults age 18, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov

For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the Facility representative, Kaneez Jaffery

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2022 01:33 PM - It Cannot Be Edited

Created By: Justin Giese On 09/12/2022 at 12:48 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY	FACILITY NUMBER: 334846059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above in 3 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2022
	Plan of Correction
1 2 3 4	Director understnd the importance of this regulationa and will acquire immunization records for the following staff and submit to LPA/Licensing on or before the listed POC date of 10/12/2022 S1: MMR, S2: MMR/Tdapt, S5: Tdapt justin.giese@dss.ca.gov

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2022
	Plan of Correction
1 2 3 4	Director understnd the importance of this regulation and will acquire Mandated Reporter Certificates for the following staff and submit to LPA/Licensing on or before the listed POC date of 09/26/2022 S1, S4, S5 justin.giese@dss.ca.gov

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:

Gilbert Sena

LICENSING EVALUATOR NAME:

Justin Giese

LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 09/12/2022 01:33 PM - It Cannot Be Edited

Created By: Justin Giese On 09/12/2022 at 12:48 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY	FACILITY NUMBER: 334846059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216.1(g)

Teacher Qualifications and Duties

(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2022
	Plan of Correction
1 2 3 4	Director understands the importance of this regulation and wil acquire proof of education for the following employees and submit to LPA/icensing on or before the stated POC date of 10/12/2022 S3, S4 justin.giese@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Gilbert Sena

LICENSING EVALUATOR NAME:

Justin Giese

LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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