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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843032
Report Date: 08/30/2021
Date Signed: 08/30/2021 04:18:05 PM

Document Has Been Signed on 08/30/2021 04:18 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 SCHOOL - FONTANAFACILITY NUMBER:
364843032
ADMINISTRATOR:CYNTHIA DAVILAFACILITY TYPE:
830
ADDRESS:7370 W. LIBERTY PARKWAYTELEPHONE:
(909) 200-4747
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
08/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Deseree Jones Director and Nel Jayawardana OwnerTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Diana Brasel arrived at the facility on that above noted date and time to conduct 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 08/24/2021 and date stamped on 08/25/2021. The facility reported on the following information :
On Monday 08/23/21 at 11:11 am a child was left outside on the playground as the class of 7 children with 2 staff members transitioned into the classroom. A review of video footage shows the teachers realized that the child was not in the class at 11:15 am leaving the child outside for 4 minutes. LPA reviewed the video footage, gathered statements from staff of the incident, conducted interviews, and gathered additional at time of visit.

Based on the information gathered, the following violation has been identified:
101429 Responsibility for Providing Care and Supervision for Infants.
(a) In addition to Section 101229, the following shall apply:
(1) Each infant shall be constantly supervised and under direct visual observation and
supervision by a staff person at all times.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to facility staff.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Diana Brasel
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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 08/30/2021 04:18 PM - It Cannot Be Edited


Created By: Diana Brasel On 08/30/2021 at 03:24 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: ST. MARY'S MONTESSORI SCHOOL - FONTANA
FACILITY NUMBER: 364843032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited
CCR
101429(a)(1)

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Responsibility for Providing Care and Supervision for Infants
(a) In addition to Section 101229, the following shall apply: (1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement
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The Director is providing daily reminder notices via email to all teachers regarding the proper procedure to ensure no child is left unsupervised. Management conducts constant training and in service trainings.
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was not met as evidence by: Staff reported to management, then management reported to Licensing that a child was left outside for 4 minutes on 08/23/2021 without constant and direct supervision. This poses as an immediate health and safety risk to children in care. Civil penalties assessed.
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POC cleared at time of visit.

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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:Diana Brasel
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
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