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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846059
Report Date: 04/19/2024
Date Signed: 04/19/2024 12:36:59 PM

Document Has Been Signed on 04/19/2024 12:36 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 ACADEMYFACILITY NUMBER:
334846059
ADMINISTRATOR/
DIRECTOR:		JAFFERY, KANEEZFACILITY TYPE:
850
ADDRESS:2266 GRIFFIN WAYTELEPHONE:
(951) 340-2821
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 78TOTAL ENROLLED CHILDREN: 78CENSUS: 26DATE:
04/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Kaneez Jaffery, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:46 PM
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Licensing Program Analyst (LPA), Elyse Jones conducted an annual inspection as part of a compliance review. A tour of the inside and outside of the facility was granted and the following was observed and/or noted:
This is not a combination center. This facility has a toddler option.
Water testing was completed on 12-14-22
A review of staff and children's records were conducted as part of this evaluation.
· The licensee/director is asked to update the following documents, if applicable, and submit to licensing within 30 days:
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 (only if changes have been made)
5. LIC 308 Designation of Administrative Responsibility (only if changes have been made)
· 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 not operating within the limits as stated on the license.
· Ratios are not being met during this inspection
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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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: 04/19/2024
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·Classrooms are adequately equipped with age and size appropriate furniture and equipment and free of hazards.
· There are no weapons present at the facility as stated by Kaneez Jaffrey, Director.
· 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.
· Present for supply drinking water in the indoor activity space
· Medications are stored where inaccessible to children.
· Hazards are stored where inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
· Poisons and toxins are locked
· 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
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, 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 outdoors and provided by delivered filtered water. Each classroom has a water pitcher to refill personal cups. The facility also has drinking water fountains.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall,
· 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 6/2025
· Opening and closing staff member’s CPR/First Aid expires on Opener-5/25, Closing 5/25
· Director completed Health and Safety Training- On file
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
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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: 04/19/2024
NARRATIVE
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·A review of children’s records was conducted, and records were found to be incomplete during this inspection.
· Disaster drills to be conducted every six months – last drill conducted on 8-11-2023
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· A review of staff records on 4-19-2024 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
· A review of staff records indicates that all staff present did not meet minimum qualifications for the position for which they were hired.

LPA discussed the safe sleep regulations with Kaneez Jaffrey, Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Kaneez Jaffrey, Director the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. 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
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
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: 04/19/2024
NARRATIVE
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Kaneez Jaffrey, Director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- To access on-line Licensing forms & Regulations for a Child Care Center please visit: www.ccld.ca.gov.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200



See LIC809-D for cited deficiencies.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with Kaneez Jaffrey, Director.
A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2024 12:36 PM - It Cannot Be Edited


Created By: Elyse Jones On 04/19/2024 at 11:47 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.4(a)
This requirement is not met as evidenced by:
101216.4 PRESCHOOL PROGRAM WITH TODDLER COMPONENT
(a) Licensees serving preschool-age children may create a special program component for children who are between 18 months and 36 months of age. The provisions of Sections 101151 through 101239.2 shall apply for children over 24 months, in addition to those specified in Health and Safety Code section 1596.955. The provisions of Sections 101351 through 101439.1 shall apply for children between the ages of 18 and 24 months participating in a preschool toddler component, in addition to those specified in Health and Safety Code section 1596.955.
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Safety risk to the children in care. During review of children’s files the LPA was unable to review Sleep Logs or Infant Needs & Service Plan for C4.
POC Due Date: 04/30/2024
Plan of Correction
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Director understands all children enrolled in the Toddler Option who are between ages 18-24months must follow regulation sections 101351 through 101439.1. Infant Needs and Service Plan is regulation 101419.2 and Sleep Logs is regulation 101429(a)(2)(B). Director agrees to obtain an Infant Needs & Service Plan from Authorized Representative and sleep logs up to 4-29-2024 and submit to the Department on or by POC due date of 4-30-24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2024 12:36 PM - It Cannot Be Edited


Created By: Elyse Jones On 04/19/2024 at 11:50 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Safety risk to the children in care. During review of fire drill log LPA was unable to verify a documented fire drill conducted within the last six months. The last fire drill documented is 8-11-23.
POC Due Date: 04/30/2024
Plan of Correction
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Director understands fire drills must be conducted at least once every six months. Director agrees to conduct a fire drill, document and submit to the Department on or by POC due date of 4-30-2024.
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
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Safety risk to the children in care. During staff file review LPA was unable to review a current Mandated Reporter certificate for S3. The Mandated Reporter certificate on file expired on 6-27-2023.
POC Due Date: 04/30/2024
Plan of Correction
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Director understands all staff must have a current Mandated Reporter certificate on file. Mandated Reporter training must be retaken every two years. Directors agrees to have S3 complete the Mandated Reporter training and will submit the certificate of completion to the Department on or by POC due date of 4-30-24. Training can be completed at www. Mandatedreporter.com
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/19/2024 12:36 PM - It Cannot Be Edited


Created By: Elyse Jones On 04/19/2024 at 11:50 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

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
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Health risk to the children in care. During staff file review LPA was unable to review immunizations for S3 and S7.
POC Due Date: 04/30/2024
Plan of Correction
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Director understands all staff must have immunizations and record must be available for review. Immunizations required include MMR & DTap. Director agrees to have staff obtain a copy of immunizations or Titers test results. Director agrees to submit proof of immunization to the Department on or by POC due date of 4-30-24.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During review of children’s files the LPA was unable to review an LIC 701, Physician’s Report for C2.
POC Due Date: 04/30/2024
Plan of Correction
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Director understands prior to enrollment or within 30 days of enrollment a child must have Health Assessment completed and documented on an LIC 701, Physician’s Report. C2 has been enrolled longer than 30 days at the time of inspection. Director agrees to have C2s Authorized Representative obtain an LIC 701, Physician’s Report and agrees to submit it to the Department on or by POC due date of 4-30-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


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