<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846780
Report Date: 09/03/2025
Date Signed: 09/03/2025 04:52:31 PM

Document Has Been Signed on 09/03/2025 04:52 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:COUNTRYSIDE MONTESSORI ACADEMYFACILITY NUMBER:
334846780
ADMINISTRATOR/
DIRECTOR:		JAFFERY,ZAINABFACILITY TYPE:
860
ADDRESS:2266 GRIFFIN WAYTELEPHONE:
(951) 340-2821
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 74TOTAL ENROLLED CHILDREN: 74CENSUS: 35DATE:
09/03/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Manoj Wickremesinghe licensee and Zainab Jeffery DirectorTIME VISIT/
INSPECTION COMPLETED:
05:00 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 the above noted date and time, Licensing Program Analyst (LPA), Diana Brasel conducted an announced Pre-Licensing inspection to add an infant component to the existing preschool with an attached toddler option component. The facility will become a single license with preschool, toddler option and infant components. Facility number 334846059 is the current facility number which will be closed upon completion as a single license conversion. Upon arrival, LPA met with Manoj Wickremesinghe licensee and Zainab Jeffery director. Licensee originally requested to be licensed for 74 children, 8 infants, 20 toddlers and 46 preschool children. Upon measuring and tour due to amount of toilets for the preschool children and updated LIC 200A has been obtained to reflect the requested capacity of 74 children, 8 infants ages 6 weeks - 18 months in room 3, 21 toddler option children ages 18 months-3 years of age in room 1, and 45 preschool children ages 2-5 in rooms 2 and 4.
Hours of operation will be Monday - Friday 6:30am - 6:00pm..

All indoor and outdoor activity space utilized for the children was inspected today. LPA informed Zainab Jeffery that staff are required to maintain direct visual supervision of the children at all times during indoor and outdoor activities. When medications are on site, directors office. If refrigeration is needed for medication it will be stored in kitchen refrigerator, stated the licensee. A fully equipped first aid kit is in directors office. There is an operational carbon monoxide detector on site located room 3 and kitchen. All required licensing documents were observed posted in the entrance foyer/office area. Children will be signed in and out at the entrance to facility in designated books.

Fire clearance was granted on 07/01/2025
NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Diana Brasel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846780
VISIT DATE: 09/03/2025
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
26
27
28
29
30
31
32
LPA continued to tour the facility and measured all indoor and outdoor activity space. Total indoor activity space measured for infants 353.77, toddler option 861.49, and preschool 1649.88, which is sufficient to accommodate the requested capacity of (8) infant children, (21) toddler option children, and (45) preschool children. LPA observed all indoor activity space to be complete with age-appropriate furniture and equipment, including tables, chairs, cubbies, cribs, napping cots/mats, for infants who can climb out of a crib, bookshelves, and other activity supplies for the children. Toys are safe with no sharp edges, splinters, or points, nor made of small parts that can present a choking hazard. Drinking water is available in the classrooms via children's brought own water bottles filled with bottled filtered water. The facility has paper cups if needed. LPA observed all hazardous items to be inaccessible to children. There are no bodies of water or weapons on the property.

High chairs and feeding tables have broad-based legs, plastic seats are in good repair and trays lock onto chairs. High chairs are made of washable, moisture-resistant material. Changing tables have at least 1” padding covered with moisture-resistant, washable material. Sides of the changing table are at least 3” high and the changing table is within arm’s reach of a sink. Diapering sink is not used for meal preparation or dishwashing. Cribs meet regulatory requirements. Crib area is separated from activity space via solid wall. This barrier is at least four feet high, made of sound absorbing material and allows for supervision of napping children. Sleep logs are kept in infant room 3 and toddler option room 1. NAME AREA). Needs and Services Plans and Sleep Plans are kept in (NAME AREA).
There is at least one potty chair or toilet for every five infants. LPA observed a total of (1) sink for infants to be purchased (correction), 2 sinks for toddler option (1) to be purchased (correction), and 3 sinks for preschool children's use. These are sufficient to accommodate the total requested capacity of (74) children. There is a separate staff restroom equipped with a toilet and a sink. The isolation area for children who are ill will be the directors office.

Facility will provide breakfast, lunch, and pm snack. The kitchen area currently includes sink, microwave, air fryer, stove/oven, refrigerator and freezer. The kitchen area and food storage areas were observed to be free of rodents and/or vermin. Food was observed to be properly stored separate from cleaning materials. Hazardous items in kitchen are inaccessible to children via a latched door.
NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Diana Brasel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846780
VISIT DATE: 09/03/2025
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
26
27
28
29
30
31
32
The facility currently has a fully fenced playground area which is separate from other components. Fencing is wrought iron and is at least four feet high. The current fencing separating the infant playground and the preschool/toddler option playground measures 3 feet tall (correction needed) The total square footage for all the outdoor activity space is for infants 649.82, preschool/toddler option 5206.77, which is sufficient to accommodate the requested capacity for all components. An existing waiver in on file for current facility number 334846059 to have the preschool and toddler option children share the playground using a time schedule for different times for am and pm. A request to update with the single license number will be granted prior to licensure. Shade is provided via wind sails and permanent wood awnings attached to building for both playgrounds. There are sufficient outdoor age-appropriate toys and play equipment available on the playground. There is an age appropriate climbing structure on the preschool playground along with two additional large climbing equipment, which are all properly anchored. There is adequate cushioning in fall zones of climber provided by rubber matting. Drinking water is available via children's brought water bottles and drinking fountain. LPA observed all hazardous items on the playground to be inaccessible to children. Licensee Manoj Wickremesinghe and director was reminded that any changes to the facility must be reported to and approved by Community Care Licensing.

If the facility has had a lead test completed within the last five years from the pre-licensing visit date (12/10/22) and is using the same outlets, you may submit a waiver request from the lead testing requirement to the Regional Office if needed.

Licensee 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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Diana Brasel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846780
VISIT DATE: 09/03/2025
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
26
27
28
29
30
31
32
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) or (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.

Safe Sleep (for infant centers)– Child Care Centers and Family Child Care Homes:
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 licensee and director of 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.

MyChildCarePlan.org--Child Care Centers and Family Child Care Home:


Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms. 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.
NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Diana Brasel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: COUNTRYSIDE MONTESSORI ACADEMY
FACILITY NUMBER: 334846780
VISIT DATE: 09/03/2025
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
26
27
28
29
30
31
32
LPA reviewed with licensee and director the LIC 311A, Records to Be Maintained at the Facility, for child’s records, personnel records, administrative records, and documents to be posted.

The following corrections are needed prior to the issuance of the new single license:
Infant indoors:
1. Proof of a children's sink being installed, shall be submitted.
2. Proof of at least one potty chair has been purchased, shall be submitted.
3. Proof that the area on the built in cabinet with compressed wood has been repaired, shall be
submitted.
4. Proof that all lower glass windows, all walls and baseboards have been cleaned, shall be
submitted.
5. Proof that the exposed metal plate located outside of napping area has been made inaccessible,
shall be submitted.
6. Proof that the small are of the rubber strip separating the carpet from the tile, shall be submitted.
Infant outdoor:
1. Proof that the wrought iron fencing separating the infant playground from the preschool/toddler
option playground measures at least 4 feet tall, shall be submitted. Currently it measures 3 feet tall.
Toddler Option:
1. Proof of a children's sink being installed, shall be submitted.

Preschool:
1. Proof that all exposed compressed wood on the children's cabinet sink are has been repaired, shall be submitted.

Exit interview conducted and report was reviewed with the licensee and director on this date. A copy
of the report was provided. Licensee Representative understands that all proof of corrections must be provided to the Department within 30 days, or the application may be denied.
NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Diana Brasel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6