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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010437
Report Date: 05/12/2026
Date Signed: 05/12/2026 03:40:47 PM

Document Has Been Signed on 05/12/2026 03:40 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FAIRFIELD MONTESSORIFACILITY NUMBER:
483010437
ADMINISTRATOR/
DIRECTOR:		DEDENU H PANNIPITI ARACHCHFACILITY TYPE:
850
ADDRESS:1101 UTAH STREETTELEPHONE:
(707) 427-1442
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 34TOTAL ENROLLED CHILDREN: 30CENSUS: 23DATE:
05/12/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:56 PM
MET WITH:Dedunu Harshani Pannipiti ArchcTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 05/12/26 Licensing Program Analysts (LPAs) Jessica Gaumann and Amy Strother visited the facility for the purpose of conducting staff interviews. LPAs met with Director (D1), Dedunu Harshani Pannipiti Archch.

When LPAs arrived, 23 children were observed on nap mats, some sleeping and some awake, within two separate rooms. Children were supervised by two staff, D1 and S1. LPA Strother observed 3 nap mats to have exposed foam, all mats could not be observed due to sleeping bags covering mats. LPA Strother asked if any other staff were present. D1 stated fully qualified aide S2 was here from 8:30am-12:30pm. D1 and S1 stated that from 10:30am – 11:40am S1 was not present at the facility. D1 stated at 2:00pm that unfortunately the facility was out of ratio for 1 hour and 10 minutes while she and S2 had 23 children in care.

LPA Gaumann conducted additional interviews with D1 and S1 beginning at 2:12pm. LPA Strother reviewed S2's file. Based on record review, S2 had evidence of 9 Early Childhood Education units.

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

Exit interview conducted and report was reviewed with Director (D1), Dedunu Harshani Pannipiti Archc.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809-D. Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Jessica Gaumann
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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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Document Has Been Signed on 05/12/2026 03:40 PM - It Cannot Be Edited


Created By: Jessica Gaumann On 05/12/2026 at 02:58 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: FAIRFIELD MONTESSORI
FACILITY NUMBER: 483010437

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2026
Section Cited
CCR
101216.3(a)

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(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below

This requirement has not been met as evidenced by:
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D1 stated that S2 has completed 12 units and will update S2's file to reflect the completed units and send a copy of completed units. D1 will also submit a statement of how she will ensure that correct staffing ratio is met daily to LPA Gaumann via email: jessica.gaumann@dss.ca.gov by 05/26/26
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Based on interview at 2:00pm D1 stated that for 1 hour and 10 minutes, from 10:30am-11:40am, she and S2 had 23 children in care and were out of ratio when S1 was absent from the facility, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/26/2026
Section Cited
CCR101239.1(b)(5)

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(b) Floor mats used for napping shall be: (5) Maintained in a safe condition with no exposed foam.

This requirement has not been met as evidenced by:
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D1 stated she will discard all mats with exposed foam and replace with new mats. D1 will send a copy of the purchase order for the new mats to LPA Gaumann via email: jessica.gaumann@dss.ca.gov by 05/26/26
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Based on observation, 3 out of 13 sleeping mats were observed to have foam exposed due to rips in the vinyl, which poses 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.
Melinda Mohr
NAME OF LICENSING PROGRAM MANAGER:
Jessica Gaumann
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
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