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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004260
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:21:10 PM

Document Has Been Signed on 09/28/2023 01:21 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:EDISON MONTESSORI SCHOOLFACILITY NUMBER:
414004260
ADMINISTRATOR:ANGELA TANGFACILITY TYPE:
850
ADDRESS:303 TWIN DOLPHIN DRIVE, # 104TELEPHONE:
(650) 593-6824
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 28DATE:
09/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Angela TangTIME COMPLETED:
01:25 PM
NARRATIVE
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On 9/28/2023 at 9:00AM., Licensing Program Analysts (LPAs) Luis J. Gomez, Jonathan Tse met with Director, Angela Tang. Purpose of this report is to cite facility for deficiencies observed during facility’s unannounced, 10 day complaint inspection. Present during inspection was the director and 4 staff caring for 28 children. LPA inspected facility for health and safety hazards.

At 9:22AM, Based on observations, LPAs confirmed accessible broken play equipment in the outdoor play yard. Deficiency issues on attached case management report.



At 9:28AM., Based on observations, LPAs confirmed deceased rodent in the outdoor play area. Rodent was removed by building maintenance during inspection. Advisory Note: Technical Violation (LIC9102TV) was issued.

Based on today’s inspection, deficiencies were observed in areas evacuated according to the Title 22, Division 12, Chap, 1 of Ca, Code of Regulations and cited on the 809D. An exit interview, report, appeal rights, and plan of correction was discussed with the Director, Angela Tang, and signature of this form acknowledges the receipt of these documents.

A copy of this report and appeal rights were reviewed and provided to the Director.
Notice of site visit was given and shall remain posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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 09/28/2023 01:21 PM - It Cannot Be Edited


Created By: Luis Gomez On 09/28/2023 at 12:40 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: EDISON MONTESSORI SCHOOL
FACILITY NUMBER: 414004260

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
101239(o)(1)

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101239(o)(1) Fixtures, Equipment and Supplies :(1) Equipment shall be maintained in a safe condition, free of sharp, loose or pointed parts. This requirement was not met as evidenced by:
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Director will submit plan to the department ensuring the daily review and removal of potential health and safety hazards for the outdoor play area by the due date: 10/6/2023.
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At 9:22AM, Based on observations, LPAs confirmed accessible broken play equipment in the outdoor play yard. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to the Department via email.

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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
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