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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490111657
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:19:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2024 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240124172141
FACILITY NAME:BRUSH CREEK MONTESSORI SCHOOLFACILITY NUMBER:
490111657
ADMINISTRATOR:SUSAN MORRELLFACILITY TYPE:
850
ADDRESS:1569 BRUSH CREEK ROADTELEPHONE:
(707) 539-7980
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:78CENSUS: 48DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Anna GarciaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is operating out of ratio.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Strother made a subsequent complaint-investigation visit and met with facility representative, Anna Garcia for the purpose of delivering findings for the above allegation. It has been alleged that the facility is operating out of ratio.

LPA previously met with Center Director, Susan Morell (D1) on 01/31/24 to initiate the investigation by discussing the purpose of the visit, conducting interviews with D1 and 10 staff (S1-S10), the previous report dated 01/31/24 reported interviews with 11 staff, however D1 was one of those 11 staff persons. D1 denied the allegation stating that although they have had to move children from one room to another or call the office manager in to meet ratios due to staffing shortages, the classrooms have not been out of ratio.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 01-CC-20240124172141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BRUSH CREEK MONTESSORI SCHOOL
FACILITY NUMBER: 490111657
VISIT DATE: 04/03/2024
NARRATIVE
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On 01/24/24 the Regional Office received records pertaining to the allegation. During the initial investigation visit on 01/31/24, LPA made observations, and received the following documents: a current roster of children in care, current LIC500, staff schedule and sign-in/sign out records for all four classrooms for the month of January 2024. A review of records received on 01/24/24 indicates that at 8:48am, on an undisclosed date, a staff person working in Amber, a preschool classroom, had 13 children in their care and the a staff person working in Saplings, a toddler classroom, had 8 children in care. A review of sign-in records for 01/23/24 indicate that Amber had 13 children signed into care by 8:43am. The staff schedule received on 01/31/24 indicated that the second teacher begins their shift at 8:45am.

Statements provided by staff (S2, S4, S5, S6, S8 & S10) reported that they have witnessed on one or more classrooms operate out of ratio. S2 stated that they have had 10 toddlers in their care prior to the next teacher’s arrival at 9:00am, and although they were instructed to call the office manager to come in to meet ratios, they weren’t able to do so due to their care responsibilities; helping children transition and separate from their parents at drop-off. LPA’s review of 17 days of sign-in sheets for the month of January reveal that more than 6 children and up to 10 children arrived prior to 9:00am on 11 out of the 17 days, indicating that a second staff was required for the majority of days care was provided in January. S2 also reported that they observed 27 children in the Redwood preschool classroom with 2 teachers present on 01/11/24. S4 stated that they have worked in the Amber classroom alone, supervising 13 or 14 children. S5 reported that while working in the Saplings, a toddler classroom, they independently cared for 8 children for 10-15 minutes prior to another teacher’s arrival on more than one occasion during the month of January. S5 also stated that they have witnessed a teacher leave one teacher with 20 preschool children on the Redwood play yard, while going inside to retrieve something. S6 stated that they have arrived to work in a toddler classroom where there was one teacher with 7 toddlers prior to her arrival. S8 stated that they observed 27 children on the Redwood play yard with 3 teachers, when one of the 3 teachers took one child inside for an icepack, leaving 2 teachers out of ratio with 26 children. S10 denied the allegation that any classroom was ever over ratio but did corroborate that the Seedlings toddler classroom was scheduled in a way that relied on children arriving late, at a time after the second staff’s arrival, to meet ratio requirements. S10 also stated that there was a backup plan and expectation that the teacher would call the office manager to come into the classroom to meet ratios.

Continue on LIC9099-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 01-CC-20240124172141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BRUSH CREEK MONTESSORI SCHOOL
FACILITY NUMBER: 490111657
VISIT DATE: 04/03/2024
NARRATIVE
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This is sufficient evidence to support claims regarding the facility operating out of ratio and to show the facility did not comply with requirements of Teacher-Child ratios of 1 to 12 for preschool and 1 to 6 for toddlers. The facility will be cited under California Code of Regulations (CCR) 101216.3(a).

Based on records received and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is cited on the attached LIC9099-D.

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. Appeal Rights were provided and this report reviewed with facility representative, Anna Garcia.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 01-CC-20240124172141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BRUSH CREEK MONTESSORI SCHOOL
FACILITY NUMBER: 490111657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
CCR
101216.3(a)
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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 is not met as evidenced by:
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Facility Representative stated she would have a conversation with the Center Director to come up with a written plan to ensure compliance with the ratio requirements. The written statement will be submitted via mail or email. amy.strother@dss.ca.gov
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Based on statements provided by staff S2, S4, S5, S6 & S8 and a review of sign-in and staff scheduling records, the facility was operating over ratio on multiple days during the month of January, which posed a potential health, safety and/or personal rights risk to the children 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.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4