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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846067
Report Date: 06/02/2023
Date Signed: 06/02/2023 10:35:11 PM


Document Has Been Signed on 06/02/2023 10:35 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:GOODEARTH MONTESSORI SCHOOLFACILITY NUMBER:
364846067
ADMINISTRATOR:ESCOBEDO, ALICEFACILITY TYPE:
850
ADDRESS:2593-A CHINO HILLS PKWYTELEPHONE:
(909) 393-0998
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:156CENSUS: 81DATE:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Alice EscobedoTIME COMPLETED:
03:45 PM
NARRATIVE
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During a unannounced visit, Licensing Program Analyst (LPA) Rachel Zeron, was made aware that the facility failed to report an incident that the facility had water damage to Community Care Licensing (CCL) within the 24 hour period and send an Unusual incident report to the department. The Director indicated that as of this date, Licensing has not been notified. The facility is in violation of reporting requirement and will be issued a citation.

See LIC809D for cited deficiencies. Appeal rights were discussed and a copy was provided.

An exit interview was conducted with the Director, Alice Escobedo and a copy of this report was provided this date.

A NOTICE OF SITE VISIT WAS GIVEN. DIRECTOR WAS INSTRUCTED TO POSTED IT IN A PROMINENT LOCATION AT THE FACILITY. THE DIRECTOR UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951)320-2023
LICENSING EVALUATOR NAME: Rachel ZeronTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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 06/02/2023 10:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: GOODEARTH MONTESSORI SCHOOL
FACILITY NUMBER: 364846067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements: a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)below shall be submitted to the Department within seven days following the occurrence of such event. Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Director agrees to send an incident report to the Department, regarding the water damage incident by POC date. Director agrees to submit an incident report going forward for those requiring reporting. email address for reporting is: UnusualIncidentReportsDO09@dss.ca.gov
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This requirement is not met as evidenced by:
Based on information received, the Child care center sustained water damage and failed to report this to CCL.
This poses 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: Aaron RossTELEPHONE: (951)320-2023
LICENSING EVALUATOR NAME: Rachel ZeronTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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