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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841885
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:09:53 PM

Document Has Been Signed on 02/29/2024 12:09 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:ST. MARY'S MONTESSORI SCHOOLFACILITY NUMBER:
364841885
ADMINISTRATOR:EMILY TURNERFACILITY TYPE:
850
ADDRESS:6880 N VICTORIA WINDROWS LOOPTELEPHONE:
(909) 200-2727
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY: 209TOTAL ENROLLED CHILDREN: 209CENSUS: 143DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nel Jayawardana/administratorTIME COMPLETED:
12:30 PM
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On 2/29/24 at 8:30 am, Licensing Program Analyst Patricia Berry conducted a case management visit in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 2/23/24. It was reported a child fell forward in a chair and child bumped the lip. The injury resulted in the child losing a tooth. I

Staff were interviewed. Staff stated there were 3 staff to 17 children. Based on information gathered, staff did not properly supervise child. Staff did, however, immediately change their routine at lunch time, staff immediately conducted a training on supervision, and staff immediately reported the incident to parents and Community Care Licensing.

LIC 9102 Advisory Note Technical Violation was issued for the incident.

An exit interview was conducted, and a copy of this report and appeal rights was provided to facility staff.

Notice of Site was was issued and must be posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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