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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010437
Report Date: 09/26/2024
Date Signed: 09/26/2024 02:12:26 PM


Document Has Been Signed on 09/26/2024 02:12 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:FAIRFIELD MONTESSORIFACILITY NUMBER:
483010437
ADMINISTRATOR:KUMAR, UMA DEVIFACILITY TYPE:
850
ADDRESS:1101 UTAH STREETTELEPHONE:
(707) 427-1442
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:34CENSUS: 19DATE:
09/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Center Director Monika VermaTIME COMPLETED:
02:10 PM
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Licensing Prorgram Analyst (LPA) Elpidia Hernandez Torres arrived to the facility, to conduct a plan of correction visit. The center was previously issued a type B deficiency on 09/17/2024, due to children's records missing blue CDPH 286 with immunization transcribed.

LPA reviewed the same seven children's records and observed six of the children had immunization records and blue CDPH 286 filled out on file. One child was still missing their immunization record, center director was able to show proof of communication with the guardian requesting missing items for child's file.

Some children's records were still missing LIC 701 physician's report, center director was able to show communication with the guardians requesting the physicians reports or appointment date for when the child will be going to the doctor.

LPA also reviewed the sign in/ out procedure that needed additional support the previous date LPA was present. Since 09/17/24 the sign in/ out only had one day where a few children were not signed out, the center did communicate with the guardians and are working on ensuring full participation on the sign in/ out procure.

There were no deficiencies issued during todays visit. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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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