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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364841885
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:29:29 AM

Document Has Been Signed on 08/28/2023 11:29 AM - 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:MARTINEZ DESERIEFACILITY TYPE:
850
ADDRESS:6880 N VICTORIA WINDROWS LOOPTELEPHONE:
(909) 200-2727
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY: 209TOTAL ENROLLED CHILDREN: 209CENSUS: 147DATE:
08/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emily TurnerTIME COMPLETED:
11:45 AM
NARRATIVE
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On 8/28/23 at 10:00 am, Licensing Program Analyst's (LPA's) Patricia Berry and Diana Brasel 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 8/4/23. It was reported an alleged incident occurred on 5/4/23, staff inappropriately grabbed a child. The incident was reported to CCL on 8/4/23.

Facility records were obtained. LPA interviewed all pertinent parties. Based on information gathered, the facility acted appropriately, and no violations have been identified. The facility conducted their own internal investigation and found no violation.

The facility, however, did not report the incident to CCL in a timely manner. The incident occurred on 5/4/23 and was first report to CCL on 8/4/23.

See 809D for deficiency.

An exit interview was conducted with the administration, and a copy of this report was provided, appeal right and notice of site visit.

Notice of site visit must be posted for 30 days.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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 2
Document Has Been Signed on 08/28/2023 11:29 AM - It Cannot Be Edited


Created By: Patricia Berry On 08/28/2023 at 07:10 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: ST. MARY'S MONTESSORI SCHOOL
FACILITY NUMBER: 364841885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
CCR
101212(d)(D)

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Reporting Requirements (d) ... during the operation of the childcare center... a report shall be made ...within the Department's next working day ... (D)Any suspected physical or psychological abuse of any child.
This requirement was not met a evidenced by
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Administrator sent the Unusual Incident Report to CCL 8/4/23. Administrator stated she will send a written statement of acknowledgment, understanding and compliance to regulation 101212 (d) (D) by 9/1/23.
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Based on record review the incident on 5/4/23 was not reported to Community Care Licensing until 8/4/23 and was not reported in a timely manner.

This is a potential risk to the health and safety pf children 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:Gilbert Sena
LICENSING EVALUATOR NAME:Patricia Berry
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
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