434400025-8-15-2022-52-CC-MPRE-CHBSWJ-20220815141425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400025
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:14:43 PM

Document Has Been Signed on 08/15/2022 02:14 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	PALO ALTO MONTESSORI SCHOOL INC.		FACILITY NUMBER:	434400025
ADMINISTRATOR:	SOMA GUNAWARDENA		FACILITY TYPE:	850
ADDRESS:	575 ARASTRADERO ROAD		TELEPHONE:	(650) 493-5930
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY: 40	TOTAL ENROLLED CHILDREN: 34	CENSUS: 32	DATE:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Dinesh Perera		TIME COMPLETED:	02:10 PM

NARRATIVE

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On 8/15/2022 at 10:20am Licensing Program Analyst (LPA) Morgan Pringle met with Co-Director Dinesh Perera for an Unannounced Annual Inspection. There were thirty-two (32) preschool age children and five (5) other staff present during the inspection. Two (2) classrooms were toured for a health and safety inspection. The facility operates from 7:30am – 5:30pm, Monday – Friday.

The facility has ample age appropriate materials in the classrooms that were observed to be clean and in good condition. All toxins, medications, cleaning products, and hazardous materials were observed to be in inaccessible areas. There are four (4) toilets, and four (4) sinks at the facility. Both bathrooms are clean and in proper working order. There is also one (1) adult sized sink in the classroom closest to the entrance of the facility. All children have access to clean drinking water in and outside of the classroom. There is a working carbon monoxide, smoke detector, and a fully charged fire extinguisher in both classrooms. The outside play yards are fully fenced, clean, and free from hazards with plenty of shade. The small play structures are sturdy and anchored into the ground. The sand box is free from hazards and properly maintained. LPA did not observe any harmful or unattended bodies of water in or around the facility.

The facility is operating within its licensed capacity and is in ratio. All proper postings are made visible by the entrance door of the classroom that is closest to the entrance of the facility. The facility does not provide any food for the children. All food is brought from home by the children in care. All lunch boxes and water bottles are properly labeled. The napping equipment is clean, orderly and properly stored. The fire/disaster drill log was complete with the last drill logged 8/11/2022.

A physical census of the children and staff were taken and cross referenced with the sign-in and out log. Through LPA’s record review it was found that nine (9) children were not signed in (See LIC809-D). All staff on site have obtained a criminal record clearance. LPA obtained the facilities files, children’s files and staff files. All files were complete. Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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 08/15/2022 02:14 PM - It Cannot Be Edited

Created By: Morgan Pringle On 08/15/2022 at 01:16 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PALO ALTO MONTESSORI SCHOOL INC.	FACILITY NUMBER: 434400025
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101229.1(b)

Sign In and Sign Out

(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/17/2022
	Plan of Correction
1 2 3 4	Director will ensure that all children are signed in properly. Director will send LPA Pringle a statement including the number of children present and the number of children present for the day and the number of children signed in.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jason Jang

LICENSING EVALUATOR NAME:

Morgan Pringle

LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PALO ALTO MONTESSORI SCHOOL INC.	FACILITY NUMBER: 434400025
	VISIT DATE: 08/15/2022

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Deficiencies cited
101229.1(b) Nine Children were not signed in properly

Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Personnel Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Director was reminded that California Law requires all facilities to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov. Director was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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.

Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PALO ALTO MONTESSORI SCHOOL INC.	FACILITY NUMBER: 434400025
	VISIT DATE: 08/15/2022

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Director 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.

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.

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

Exit interview conducted and report was reviewed with Co-Director Denish Perera.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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