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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300359
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:34:47 PM

Document Has Been Signed on 05/03/2023 02:34 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
RIVERSIDE SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:COLES COTTAGE ACADEMYFACILITY NUMBER:
376300359
ADMINISTRATOR:COSTA,WEERATUNGAFACILITY TYPE:
830
ADDRESS:505 CIVIC CENTER DRTELEPHONE:
(949) 836-4465
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 20TOTAL ENROLLED CHILDREN: 1CENSUS: 13DATE:
05/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Weeratunga CastaTIME COMPLETED:
02:50 PM
NARRATIVE
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On 5/3/23 while conducting a complaint investigation on another matter, LPA Keely Messerschmidt, observed the infant classroom having 2 teachers with 9 children. LPA questioned Teacher what their ratio was, Teacher stated that their ratio is 1:4. However, the teacher stated that the third teacher stepped out to support another classroom with diapers and would be returning any minute. Director then went and had the third teacher go back into the infant classroom to maintain ratio.

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



An exit interview was conducted, and a copy of this report was provided on this date.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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 05/03/2023 02:34 PM - It Cannot Be Edited


Created By: Keely Messerschmidt On 05/03/2023 at 02:04 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: COLES COTTAGE ACADEMY
FACILITY NUMBER: 376300359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2023
Section Cited
CCR
101416.5(b)

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Staff-Infant Ratio - (b) There shall be a ratio of one teacher for every four infants in attendance.This requirement was not met as evidence by: LPA observed infant classroom with 2 teachers and 9 children. This poses an immediate risk to the health and safety of the children.
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Director, Weeratunga Costa agrees to submit a written statement on how the facility will remain in compliance with ratio as required by Title 22 Regulations.

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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:Carlos Martinez
LICENSING EVALUATOR NAME:Keely Messerschmidt
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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