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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004506
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:48:38 AM

Document Has Been Signed on 07/19/2022 11:48 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LAKEVIEW MONTESSORIFACILITY NUMBER:
414004506
ADMINISTRATOR:BRAMHE, SHEILAFACILITY TYPE:
850
ADDRESS:31 VISTA AVENUETELEPHONE:
(650) 578-9532
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 61TOTAL ENROLLED CHILDREN: 75CENSUS: 40DATE:
07/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Fida AslamTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Winnie Ly conducted case management at this location. LPA met with Fida Aslam. The purpose of the visit was explained. There were 8 staff caring for 40 children.


The case management inspection was conducted due to complaint received from the San Mateo Police Department. There was no record of self reporting from facility representatives. Reporting requirement was explained to the facility representatives.

Type B is issued in accordance with the California Code of Regulations, Title 22, see LIC 809D.

Plans of Corrections (POC) were developed and reviewed with Assistant Director. A copy of this report and appeal rights were discussed and will be emailed to Facility Representative whose signature on this form confirm have read the reports. Notice of Site Visit will also be emailed to Facility Representative. Assistant Director was inform Notice of Site Visit to remain posted for 30 days upon receipt. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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 07/19/2022 11:48 AM - It Cannot Be Edited


Created By: Winnie Ly On 07/19/2022 at 10:08 AM
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: LAKEVIEW MONTESSORI
FACILITY NUMBER: 414004506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2022
Section Cited
CCR
101212(d)(B)(D)

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101212(d)(B)(D)
Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.
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Facility representative needs to submit the UIR to the CCL Department along with a statement stating that Facility Representatives have reviewed and understood CCR 101212 Reporting Requirement for Child Care Center by 07/26/2022.

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This requirement is not met as evidenced by complaint received, record reviews, interview staff, facility representative did not self report incident by phone nor submitting LIC 624 Unusual Incident Report to the deparment.

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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:Garfield Leung
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


LIC809 (FAS) - (06/04)
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