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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404878
Report Date: 10/01/2025
Date Signed: 10/01/2025 11:19:00 AM

Document Has Been Signed on 10/01/2025 11:19 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MARIPOSA MONTESSORI SCHOOLFACILITY NUMBER:
434404878
ADMINISTRATOR/
DIRECTOR:		REKHA MUNDKURFACILITY TYPE:
850
ADDRESS:16548 FERRIS AVENUETELEPHONE:
(408) 356-8816
CITY:LOS GATOSSTATE: CAZIP CODE:
95032
CAPACITY: 70TOTAL ENROLLED CHILDREN: 65CENSUS: 13DATE:
10/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Grishma Dave - Head of AcademicsTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer "Jen" Beehler conducted an unannounced Case Management - Incident inspection. Upon arrival, LPA was greeted by Facility Representative Grishma Dave - Head of Academics and provided access to the facility. LPA stated the reason for the visit was to investigate the self reported incident that occurred on 09/19/2025. LPA toured the indoors and outdoors of the facility and collected the census.

LPA conducted interviews with staff and observed the facility.

LPA revealed through testimony that on 09/19/2025, there were three teachers present and approximately five children total in the "motor skills area" when the incident occurred. Child #1 (C1) was in the "motor skills area" observing the earth elements. C1 took the glass jar that contained sand and attempted to take it out of the observation area. Staff Person #1 (S1) asked him to return the jar to the place it is kept and C1 decided to run away with the jar in hand. C1 tripped at the transition part of the floor where it moves from carpet to linoleum. The child fell to the ground and the jar fell out C1's hands and broke when it hit the floor. C1 placed their hand in the broken glass when standing up and the glass cut the palm of C1. Staff Person #2 (S2) immediately gathered the other children and moved them away from the broken glass. S1 attended to the child. Staff Person #3 (S3) attended to the children on the other side of the classroom while S1 and S2 addressed the injury. S2 placed a paper towel over the wound and asked C1 to apply pressure. S1 left the classroom to gather the Director Rekha Mundkur. The Director and S2 took the child from the classroom to dress the wound, call parents and call 911. Emergency medical professionals reviewed the wound and determined it was stabilized and suggested the child go to the emergency room for further evaluation. C1's parent arrived and took C1 to the hospital. No stitches were required. C1 returned to school on 09/29/2025.

Continued on Page 2
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MARIPOSA MONTESSORI SCHOOL
FACILITY NUMBER: 434404878
VISIT DATE: 10/01/2025
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Staff stated the glass jars had been replaced with plastic boxes to make this activity safer for children.

Due to today's investigation, no deficiencies are cited. Exit interview conducted with Director Rekha Mundkur. Report was reviewed and provided along with appeal rights.

NOTICE OF SITE VISIT PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Jennifer Beehler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC809 (FAS) - (06/04)
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