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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444408900
Report Date: 02/24/2022
Date Signed: 02/24/2022 03:59:06 PM

Document Has Been Signed on 02/24/2022 03:59 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MONTESSORI SCOTTS VALLEY, INC.FACILITY NUMBER:
444408900
ADMINISTRATOR:TERSHY, MADELYNNFACILITY TYPE:
830
ADDRESS:123 SOUTH NAVARRA DRIVETELEPHONE:
(831) 439-9313
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 12TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Madelynn TershyTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Madelynn Tershy, for an unannounced Required- 1 Year Inspection. LPA was granted access to the facility by Licensee Assistant, Jessica Cannarozzi, and toured both indoors and outdoors during the inspection. Upon arrival, there were 10 infants and 4 staff (1 teacher, 3 assistants) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility and advised Licensee to post required postings in infant room as parents do not drop off in main lobby. Hours of operation for the facility are Monday – Friday, 7:30AM-5:30PM.

LPA reviewed sign-in/out sheets, facility roster, and fire/disaster drill log during today’s inspection. Facility has an active waiver for computer sign-in/out and roster is located digitally within facility system. Printed roster for infants was provided to LPA during inspection. The last fire/disaster drill was conducted on 12/19/2021, which is compliant with the six-month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services. Over the counter medications are properly stored out of reach of children in a locked box with proper documentation. Technical Assistance provided to Licensee regarding proper dosage of medication for infants and ensuring dosage is correct based on child's weight. The Licensee states that there are no weapons or firearms on the premises.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers, Section 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice 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
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/24/2022 03:59 PM - It Cannot Be Edited


Created By: Cortney Nelson On 02/24/2022 at 02:29 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for 1 out of 6 staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2022
Plan of Correction
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Staff member needs to obtain fingerprint clearances prior to being present at the facility. Staff cannot be present with the children until fingerprint clearances are obtained. Licensee will submit Livescan form for staff member once completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


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Document Has Been Signed on 02/24/2022 03:59 PM - It Cannot Be Edited


Created By: Cortney Nelson On 02/24/2022 at 02:29 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, the licensee did not comply with the section cited above for 3 out of 6 infant staff members, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will submit mandated reporter training certificate for staff members who are expired by 3/3/2022.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 10 infant files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
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Licensee will submit physican report for children who do not have it by 3/24/2022.
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


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Document Has Been Signed on 02/24/2022 03:59 PM - It Cannot Be Edited


Created By: Cortney Nelson On 02/24/2022 at 02:29 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above for 3 out of 10 infants, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee shall submit Individual Infant Sleeping Plan for children who do not have it by 3/3/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


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Document Has Been Signed on 02/24/2022 03:59 PM - It Cannot Be Edited


Created By: Cortney Nelson On 02/24/2022 at 02:42 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(A)
101419.2 Infant Needs and Services Plan (A) Prior to the infants first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for 3 out of 10 infants, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will submit Needs & Services Plan and Individual Infant Sleep Plan for infants who do not have in their file by 3/3/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900
VISIT DATE: 02/24/2022
NARRATIVE
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Indoor areas of the facility were inspected by the LPA and observed to be clean, orderly, and safe for day care infants. Infant room at the facility is physically separated from other childcare center components. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Toys are safe and do not have sharp edges or small parts that may pose a choking hazard. Infant changing table was observed to be padded, within arms reach of a sink, in good repair and safe condition. Infant cots are free from loose articles, covered with a fitted sheet, and there are no objects hanging above or attached to the cot. The floors are clean and free of tripping hazards and waste containers have tight fitting lids.

Feeding plan is current for most infants and Licensee understands that all formula provided should be labeled individually with the child’s name and the date. Facility currently has waiver to prepare and mix infant bottles with formula at the facility and bottles are disinfected at the end of each day. Licensee was reminded that all food and formula provided by parents/guardians should be labeled with the child's name and date.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should complete Individual Infant Sleeping Plan and all infants up to 24 months should have documented nap checks. LPA advised Licensee that nap checks should additionally have initials of staff who checked infant.

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.

Needs and Services Plan should be updated quarterly. At the facility, daily sheets are shared between staff and parents to share about updates daily. Although this provides communication between parents and staff, facility should still update written Needs and Services plan quarterly as daily sheet shared between parents and staff is written on an erasable sheet. This will allow the facility to have documented updates from parents as the daily sheets are not saved each day.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MONTESSORI SCOTTS VALLEY, INC.
FACILITY NUMBER: 444408900
VISIT DATE: 02/24/2022
NARRATIVE
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The outdoor area of the facility was inspected and observed to be fenced in and physically separated from space utilized by other child care center components. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by trees and building overhang.

10 infant files were reviewed during today’s inspection for required documents. LPA advised Licensee that infants need to have all paperwork completed prior to attendance at the facility. LPA additionally discussed quarterly Needs and Services Plan, Individual Infant Sleep Plan, and Physicians Report.

6 staff files (1 director, 1 director assistant, 1 teacher, 3 assistants) were reviewed for all required documents. There is at least one staff member present with current CPR/First-Aid that expires 08/2023. The Licensee has current Mandated Reporter Training that expires on 6/8/2023. LPA reminded Licensee that the Mandated Reporter Training must be renewed by all staff every 2 years. LPA additionally reminded Licensee to complete required Lead Poisoning Prevention training and provided link to sign-up.

The Licensee understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times.

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.

Exit interview conducted and report was reviewed with the Licensee, Madelynn Tershy.



As a result of today’s inspection, deficiencies were cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
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