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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340315188
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:23:55 PM

Document Has Been Signed on 04/18/2024 03:23 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VILLAGE MONTESSORI SCHOOLFACILITY NUMBER:
340315188
ADMINISTRATOR/
DIRECTOR:		WILLIS, LISA/AUERING, ERINFACILITY TYPE:
850
ADDRESS:5033 FAIR OAKS BLVDTELEPHONE:
(916) 488-6500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 128TOTAL ENROLLED CHILDREN: 128CENSUS: 79DATE:
04/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Lisa WillisTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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On April 18, 2024 at approximately 1:30PM, Licensing Program Analysts (LPAs) Josiah Gathing and Loraine Perez met with Director Lisa Willis to follow up on a self reported Unusual Incident that occurred on March 18, 2024. During today's inspection there were a total of 79 Preschool children supervised by 9 teachers. All individuals subject to criminal record background review have been cleared.

LPAs toured all four classrooms, made observations, and conducted interviews. The original report provided to the Licensing office described an incident in which two preschool children were blocked from the view of teachers during outdoor play. Staff also confirmed in interview that their view of the children was obscured during the incident.

Therefore, supervision requirements were not met and a deficiency is cited on the following page.

Exit interview conducted and report was reviewed with the Director, Lisa Willis. A notice of site visit was given and must remain posted for 30 days.

Title 22 deficiencies are cited on the subsequent pages of this report. Director acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided. Director signature on this report acknowledges receipt of these rights. This report was reviewed with the Director. An exit interview was conducted. A Notice of Site Visit was provided and shall remain posted for a period of 30 days for parental review.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 04/18/2024 03:23 PM - It Cannot Be Edited


Created By: Josiah Gathing On 04/18/2024 at 02:41 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLAGE MONTESSORI SCHOOL
FACILITY NUMBER: 340315188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision...(1) No child(ren) shall be left without the supervision of a teacher... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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Director will conduct a staff meeting to discuss supervision requirements. Director will provide LPA with meeting itinerary by the POC date.
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Based on interview the licensee did not comply with the section cited above as staff stated in interview, teacher's view of children was temporarily obstructed which poses/posed a potential health, safety or personal rights 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:Seychelle De Luca
LICENSING EVALUATOR NAME:Josiah Gathing
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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