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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380506275
Report Date: 09/13/2024
Date Signed: 09/13/2024 03:35:58 PM

Document Has Been Signed on 09/13/2024 03:35 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARIA MONTESSORI SCHOOL OF THE GOLDEN GATEFACILITY NUMBER:
380506275
ADMINISTRATOR/
DIRECTOR:		ALAVI, TARANEHFACILITY TYPE:
850
ADDRESS:62 LENOX WAYTELEPHONE:
(415) 731-8188
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
09/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Director, Taraneh AlaviTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 9/13/2024, at approximately 12:45PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced case management visit at the facility. LPA met with Director, Taraneh Alavi (D1), and explained the purpose of the visit. Present during the visit was D1, one staff member, and 17 preschool age children.

On 7/17/2024, LPA conducted an unannounced annual visit at the facility and observed that there was a staff member present without fingerprint clearance at the facility. LPA informed D1 that a Type A deficiency would be cited during the visit, and that the report must be made available to all parents to review. Director was informed that an Acknowledgment of Receipt of Licensing Forms must be signed by all parents and placed in each current and newly enrolled child's file for the next year (until 7/17/2025).

LPA observed that not every staff member had valid Pediatric First Aid/CPR training completed and on file. Technical assistance was provided regarding approved training programs.

On 9/13/2024, LPA reviewed three children's files and did not observe any signed LIC9224 forms to be present. LPA discussed the requirement to provide parents and authorized representatives a copy of the report dated 7/17/2024 in addition an LIC9224 with D1. D1 stated that they understood. LPA informed D1 that a Type B deficiency would be cited today. LPA and D1 discussed a plan of correction and agreed upon a due date of 9/27/2024. A copy of LIC9224 was printed and provided to D1 during the visit.

LPA observed that the staff member with valid Pediatric First Aid/CPR training was not present during today's visit. LPA discussed First Aid/CPR training requirements with D1. LPA informed D1 that a technical violation would be issued today. A plan of correction was discussed and a due date of 10/11/2024 was agreed upon.

See LIC809-D for Type B deficiency cited today regarding providing notice to parents. See LIC9102-TV for technical violation issued today regarding Pediatric First Aid/CPR requirements. A notice of site visit was provided and must remain posted for 30 days. Appeal rights were printed and explained to D1. Exit interview conducted and report was reviewed with facility representative, Taraneh Alavi.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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 09/13/2024 03:35 PM - It Cannot Be Edited


Created By: Jonathan Tse On 09/13/2024 at 02:12 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIA MONTESSORI SCHOOL OF THE GOLDEN GATE
FACILITY NUMBER: 380506275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
HSC
1596.8595(c)(1)

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 A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care...
This requirement was not met as evidence by:
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Director stated that they would provide all parents with copies of the LIC9224 in addition to copies of the facility report dated 7/17/2024, and maintain signed copies of LIC9224 in all children's files by the agreed upon due date of 9/27/2024.
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Based on record review and interview, the licensee did not comply with the above by not having signed Acknowledgment of Receipt of Licensing Forms (LIC9224) present in each child's file, which poses a potential risk to the health and safety of children 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:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
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