376700133-5-24-2023-51-CC-SBAS-CS5U3G-20230524151330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376700133
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:13:37 PM

Document Has Been Signed on 05/24/2023 03:13 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
SAN DIEGO NORTH, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	MISSION BAY MONTESSORI ACADEMY		FACILITY NUMBER:	376700133
ADMINISTRATOR:	ANDREA SUCKAU		FACILITY TYPE:	850
ADDRESS:	2640 SODERBLOM AVENUE		TELEPHONE:	(858) 457-5895
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	140	CENSUS: 100	DATE:	05/24/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Andrea Suckau		TIME COMPLETED:	03:30 PM

NARRATIVE

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LPAs Sherlynn Banas and Nancy Diaz conducted an unannounced case management inspection on May 24, 2023, at 12:50 PM regarding an Unusual Incident (UI) reported by Andrea Suckau, Center Director reported an Unusual Incident that occurred on May 17, 2023. LPAs were greeted by CD. The tour of the facility was led by the Center Director. The facility was first checked including ratio and number of teachers in the following classrooms (all children were observed napping): Room 1: 20 kids with Ana Bravo, Sakura Gatzinski, & Talat Ahmed; Rm. 2 has 21 children with the following teachers: Graciela Berumen and Michelle Richrdson; Room 3: 10 kids with the teacher Nur Arafat; Room 4 with 10 kids with the following teachers: Kiara Sloan and Nayeli Pina; Room 5 with 19 kids with the following teachers Sandra Leyva and Suzette Hermes; Room 6 with 20 kids with the teacher Maritza Gutierrez.

LPAs interviewed the Director regarding what happened on the May 17, 2023, involving a 4-year old child who sustained injury on her forehead, receiving four stitches. LPAs toured the outdoor play area. Center Director stated that staff Daniel Yang & Kiara Sloan witnessed the incident. Both staff where within a few feet away from child. First Aid was administered, at the same time, mother was called and Dad picked up the child in 10 minutes. She was brought to the Urgent Care. She came back to school the following day. No concussion was reported.

LPAs reviewed the Facility Personnel Report. It was determined that staff Talat Ahmed did not have fingerprint clearance on file. Type A deficiency was cited.

There was no deficiency cited involving the incident because the incident was an accident and can’t be prevented. No further follow-up is needed.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Sherlynn Banas	TELEPHONE: (619) 629-8368
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO NORTH, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MISSION BAY MONTESSORI ACADEMY	FACILITY NUMBER: 376700133
	VISIT DATE: 05/24/2023

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TYPE A DEFICIENCY WAS CITED. CIVIL PENALTY WAS ASSESSED.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Exit interview was conducted with Andrea Suckau. A copy of this report and appeal rights were provided today. Notice of site visit was also provided and observed posted.

SUPERVISOR'S NAME: Tashima Daniel	TELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Sherlynn Banas	TELEPHONE: (619) 629-8368
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2023 03:13 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
SAN DIEGO NORTH, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MISSION BAY MONTESSORI ACADEMY	FACILITY NUMBER: 376700133
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/25/2023 Section Cited CCR 101170(d)	1 2 3 4 5 6 7	CRIMINAL RECORD CLEARANCE. (d) All individuals subject to criminal record review shall, be fingerprinted... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Mrs. Suckau stated that she will send Mrs. Ahmed to get livescan fingerprint no later than 5/25/2023.
	8 9 10 11 12 13 14	Based on observation, record review and interview with Center Director Andrea Suckau, staff Talat Ahmed is a floater and helps staff with copying. Staff Talat Ahmed was observed in Room 1 supervising 20 napping children. Ms. Ahmed was in the classroom with 2 other teachers. Ms. Ahmed's start date is Sept. 15, 2021.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Tashima Daniel	TELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Sherlynn Banas	TELEPHONE: (619) 629-8368
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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