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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490111657
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:40:29 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
04/04/2024 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240404163527
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: 65DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Susan MorrellTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Child not given clothing

Commingling
INVESTIGATION FINDINGS:
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An unannounced complaint investigation inspection was conducted at the facility by Licensing Program Analyst (LPA), Amy Strother. It has been alleged that a child was not given clothing, specifically that on 04/04/24 a child (C1) had a bathroom accident and was placed in a pull up diaper and not given pants to wear. It has also been alleged that the facility has commingled age groups at the facility, specifically that a child over the age of three years (C1) was moved back into the toddler room in January 2024 due to the number of bathroom accidents had in the preschool room.

During today’s inspection, LPA met with Center Director, Susan Morrell (D1). D1 confirmed the allegations stating that she became aware that a child was not given pants after a potty accident on 04/04/24 when C1’s parent came to the office with C1 who was only wearing a pull up and a shirt. D1 stated that she then took C1 back to their classroom and put a pair of pants from the school supply of extra clothing on C1. D1 also confirmed that C1, a child who was over 3 years old at the time, was moved into a toddler classroom, ages 18-36 months, in January 2024 due to the number of potty accidents they were having. D1 reported that C1 was moved back in the preschool classroom after Spring Break in March 2024.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
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-20240404163527
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: 04/09/2024
NARRATIVE
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In addition to interviewing D1 during today’s visit, LPA interviewed three staff (S1-S3) beginning at 10:41am, toured the facility, and reviewed toddler room sign in/out records dated 01/08/24 to present, beginning at 11:41am. During interview with LPA, S1 stated that she did not provide pants to C1 because C1’s parents had not provided enough extra clothing, despite multiple attempts to request additional clothing. S1 stated that she was trying to convey a logical consequence to the parents, by not providing pants to C1 and requesting that C1 be picked up due to not having pants from home. Based on interviews with S2 and S3, C1 was observed either in the classroom or being picked up by a parent, wearing a pull-up diaper and a shirt, without pants. One staff interviewed stated that they observed C1 standing outside next to their parent, trying to pull the shirt they were wearing down to cover their diaper or to stay warm, since it was a cold and drizzly day. S1 and S2 confirmed that C1, who was over 3 years old at the time, was placed in the toddler classroom from January 2024 to March 2024, but then moved back into a preschool classroom after Spring Break. Prior to today’s visit, LPA interviewed Adult 1 (A1) who stated that C1 was observed standing on the deck outside on 04/04/24 wearing a diaper without pants, and pulling down on their shirt, trying to cover the diaper. A1 also stated that C1 who is was over the age of 3 years, was provided care in Seedlings, a toddler classroom, from January – March 2024. LPA’s review of both toddler rooms, Seedlings and Saplings sign in/out records dated 01/08/24 to present indicate that C1 was signed into a toddler classroom by their authorized representative from 01/08/24 through 03/15/24. Additionally, LPA observed that although C1 had been moved out of a toddler classroom after 03/15/24, there were currently six children (C2-C7) that are currently over the age of 3 still enrolled in and attending care in one of the toddler classrooms.

Based on the evidence obtained through interview and record review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California Code of Regulations, (Title 22), are being cited on the attached LIC-9099D(s). Appeal rights were provided.

LPA Strother informed facility representative, Susan Morrell that this report dated 04/09/23 documents one Type A citation. Type A citations shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the facility representative to provide a copy of this licensing report dated 04/09/24 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted, and report was reviewed with facility representative, Susan Morrell.

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: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 01-CC-20240404163527
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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2024
Section Cited
CCR
101216.4(a)(2)
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(a) Licensees serving preschool-age children may create a special program component for children who are between 18 months and 36 months of age. The provisions of Sections 101151 through 101239.2 shall apply for children over 24 months, in addition to those specified in Health and Safety Code section 1596.955. The provisions of Sections 101351 through 101439.1 shall apply for children between the ages of 18 and 24 months participating in a preschool toddler component, in addition to those specified in Health and Safety Code section 1596.955. (2) The toddler program shall be conducted in areas physically separate from those used by older or younger children. Space planning and usage for the toddler component shall be governed by the provisions of Section 101438.3. Plans to alternate use of outdoor play space must be approved by the Department.

This requirement is not met as evidenced by:
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Director (D1) stated all of the children currently enrolled in the Seedlings classroom are over the age of 24 months and plans to submit a request to change the room to be used as a preschool room (primary prep) for continuity of care purposes. Director will submit an updated facility sketch, LIC999 to update the labels on the classrooms to reflect the change. D1 will also submit a request for a waiver to use the current toddler play yard on a rotational basis between the Seedling and Sapling groups, with the daily activity schedules to be posted.
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Based on interview with staff D1, S1, S2 and Adult 1 (A1) and a review of records, C1, a child over the age of 3 years, was attending and receiving care in a toddler classroom, commingling with toddler age children 18-36 months from as early as 01/08/24 – 03/15/24. Additionally, 6 children (C2-C7) were observed to be currently enrolled and attending care in a toddler age classroom and are over the age of 3 years, which poses a potential health, safety and/or personal rights risk to the children in care.
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Additionally, D1 will send an email to all families and LPA announcing the update to the Seedlings room and have authorized representatives of children in the Seedlings room update their admission agreements. D1 will send an updated sign in sheet for each classroom, to reflect that the two children (C6 & C7) that are over 3 years and currently enrolled in the Saplings room have been moved to either the Seedlings room or alternative primary classroom.
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 01-CC-20240404163527
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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2024
Section Cited
CCR
101223(a)(3)
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101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement is not met as evidenced by:
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Director (D1) stated she is currently in the process of creating a potty training policy for the community handbook to include how potty accidents will be handled. D1 stated that she had a one on one meeting with staff S1 on 04/04/24 and will submit notes to LPA of what was covered during the meeting.
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Based on interviews conducted, S1 withheld clothing from C1,not providing C1 with the available classroom pants after having a bathroom accident on 04/04/24, which poses an immediate personal rights risk to the child in care.
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Additionally, D1 will hold a staff meeting on 04/19/24 on the topic of personal rights to include watching the Community Care Licensing video on Personal Rights and review all Personal Rights regulations in detail with staff. D1 will submit a sign in sheet with staff signatures to LPA.
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4