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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364842076
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:34:46 AM

Document Has Been Signed on 08/28/2023 11:34 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:
364842076
ADMINISTRATOR:MARTINEZ DESERIEFACILITY TYPE:
830
ADDRESS:6880 N VICTORIA WINDROWS LOOPTELEPHONE:
(909) 200-2727
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 25DATE:
08/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Emily TurnerTIME COMPLETED:
11:50 AM
NARRATIVE
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On 8/28/23 at 10:01 am, Licensing Program Analyst's (LPA's) Patricia Berry and Diana Brasel conducted a case management visit conducted in response to the receipt of an unusual incident report (UIR) from the facility. Facility records were reviewed, and staff were interviewed. Based on the information gathered, the following violations have been identified: On 8/18/23 a child was left on the playground, alone.

This is a violation of California Code of Regulations, 101429(a)(1) Title 22, Division 12.

See 809D for deficiency.


Civil penalty LIC421IM repeat violation for $1,000.00 issued today.

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

A copy of this report must be made available to the public upon request for three years.

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)
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Document Has Been Signed on 08/28/2023 11:34 AM - It Cannot Be Edited


Created By: Patricia Berry On 08/28/2023 at 07:27 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: 364842076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
101429(a)(1)

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...Providing Care and Supervision for Infants (a) In addition to ...101229,...:(1) Each infant... constantly supervised and...direct visual observation...by a staff person at all times.
This requirement was not met as evidenced by
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Teacher immediately retrieved the child from the playground. Director conducted a supervision training on tranistions and communication on 8/25/23. A list of participants was provided to LPA's on 8/28.
Also face to face training was conducted on 8/25/23.
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Based on staff interviews a child was left on the playground, alone.

This is an immediate risk to the health and safety of children in care.
Civil penalty LIC421IM repeat violation for $1,000.00 issued today.
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Teacher notified parent of the incident.
Plan of correction cleared today.

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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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