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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216182
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:02:36 PM

Document Has Been Signed on 03/30/2023 04:02 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ACORN VILLAGE MONTESSORIFACILITY NUMBER:
406216182
ADMINISTRATOR:KRISTINA PROZESKYFACILITY TYPE:
850
ADDRESS:5850 ROSARIOTELEPHONE:
(512) 461-6767
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 9DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Kristina ProzeskyTIME COMPLETED:
04:05 PM
NARRATIVE
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On March 30, 2023 at 11:50 AM , Licensing Program Analysts (LPAs) Gigi Reyes and Dixie Wright conducted an unannounced 1 year required inspection. LPAs met with Licensee Kristina Prozesky and advised her the purpose of the inspection. Facility hours of operation are Monday thru Friday 8:30 AM to 3:30 PM. Facility is located on a local church premises.

Licensee provided LPAs a tour of the Child Care Center (CCC) inside and outside. There were 9 children in care and 3 staff present at the time of the inspection. LPAs observed the required licensing documents mounted on the wall at the entrance of the facility. A posted snack menu was observed. CCC provides one snack daily for children in care.Classrooms were observed to be in order. The e playground is enclosed with appropriate wire fence with age appropriate toys and equipment. The CCC offers a half day and full day program for children. Children staying for the day is offered a cot to sleep on. The CCC has drinking water available for children from the Culligan water supplier.

LPAs reviewed children's file and found complete. Staff has first aid and CPR which expires on 1/2024. Staff 1, 2, 3 do not have immunization record on file, Early Childhood. qualifications were not verified, transcript of records were not available for review.

Continued on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: ACORN VILLAGE MONTESSORI
FACILITY NUMBER: 406216182
VISIT DATE: 03/30/2023
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During today's inspection, deficiencies were cited under Title 22 Division 12. and Health and Safety Code. Appeal Rights were given and explained,

This facility to provides Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. A Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director/Licensee Kristina Prozesky
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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Document Has Been Signed on 03/30/2023 04:02 PM - It Cannot Be Edited


Created By: Gigi Reyes On 03/30/2023 at 03:20 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: ACORN VILLAGE MONTESSORI
FACILITY NUMBER: 406216182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2023
Section Cited
CCR
101217(d)

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(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.
This requirment is not met as evidenced by
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Licensee agreed to submit the plan of correction on how to ensure that required personnel records shall be availble for review at the site, POC shall be submitted no later than 4/10/2023.
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During file review, LPAs observed that teachers qualifications are not on file. This poses a potential risk to heatlh and safety of children in care.
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Type B
04/10/2023
Section Cited
HSC1596.7995(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. This requirment is not met as evidenced by:
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LIcensee agreed to submit the plan of correction no later than 4/10/2023
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During file review, it was observed that Staff 1, 2 and 3 do not have immunization record on file. This poses a potential risk to health and safety of hcildren 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:Maria Mueller
LICENSING EVALUATOR NAME:Gigi Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


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