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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444413867
Report Date: 05/04/2022
Date Signed: 05/04/2022 01:08:04 PM

Document Has Been Signed on 05/04/2022 01:08 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:LITTLE ACORNS MONTESSORIFACILITY NUMBER:
444413867
ADMINISTRATOR:HOLLIS MEYER-DELANCEYFACILITY TYPE:
850
ADDRESS:1215 CHANTICLEER AVETELEPHONE:
(831) 464-1400
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 42TOTAL ENROLLED CHILDREN: 50CENSUS: 35DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Hollis Meyer-Delancy & Mindy Gillen TIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), James Santos arrived at the day care center today to conduct a case management visit. LPA met with Licensee, Mindy Gillen and Site Director, Hollis Meyer-Delancey and explained purpose of visit.

The purpose of the case management visit was in regards to an incident that was reported to CCL Department on 4/22/2022 that occurred on 4/20/2022.

On 4/22/2022, the Department received a phone call from the day care center Director and reported an incident that occurred on 04/20/2022 at around 11AM to 11:30AM regarding a child. Per Director, the center has about a 2.5 ft high metal fence that parents can step over to pick up the children. Per Director, the child was able to open up the fence, pushed the wooden gate and ran into the parking lot, and the teacher (S1) ran after the child and got him back safely.

During today's visit, LPA spoke with the teacher (S1) regarding the incident. The teacher stated she was with the children during play time in the play yard on that time of the incident when she saw the child opened the fence and pushed the gate open and ran into the parking lot. The teacher stated that she saw the child exiting so she followed him right away and got him back. The teacher stated that the child was in her line of vision the whole time.

Per the Director and the teacher, the gate is usually always locked after all the children have been dropped off, but on that day, they were not aware that it was not locked.

Continued on the next page.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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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: LITTLE ACORNS MONTESSORI
FACILITY NUMBER: 444413867
VISIT DATE: 05/04/2022
NARRATIVE
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During today's visit, LPA discussed with the Licensee and Director regarding safety measures to avoid any similar incidents in the future. LPA also reviewed staff files during today's visit.

According to review of record, the UIR was sent CCL on 4/22/2022.

As a result of today's visit, a deficiency has been cited, See LIC809D for deficiency.

Exit interview conducted and a copy of this report and appeal rights were reviewed and provided to the Licensee.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2022 01:08 PM - It Cannot Be Edited


Created By: James G Santos On 05/04/2022 at 12:35 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: LITTLE ACORNS MONTESSORI
FACILITY NUMBER: 444413867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements:
(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. (1) Events reported shall include the following:
(C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Licensee stated she will schedule and conduct staff training on Reporting requirements and submit proof of completion of training to CCL by POC due date of 6/3/2022.
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This requirement is not met as evidenced by:
On 4/22/2022, CCL Department received a phone call from the day care center Director and reported an incident that occurred on 04/20/2022. The telephone call was made to the Department two (working) days after the incident happened which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:James G Santos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
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