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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216042
Report Date: 06/12/2026
Date Signed: 06/12/2026 04:02:16 PM

Document Has Been Signed on 06/12/2026 04:02 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 BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SIMI VALLEY MONTESSORI SCHOOL - WEST VALLEYFACILITY NUMBER:
566216042
ADMINISTRATOR/
DIRECTOR:		ROSHINI WIREKOONFACILITY TYPE:
830
ADDRESS:15 MCCOY PLACETELEPHONE:
(818) 667-5205
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 11TOTAL ENROLLED CHILDREN: 11CENSUS: 8DATE:
06/12/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Grace Peiris TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 6/12/26, at 10:00 AM, Licensing Program Analyst (LPA) Seena Parsapour conducted an unannounced Annual/Random inspection of the abovementioned Child Care Center (CCC). LPA met with Director Grace Peiris and explained the nature & purpose of the inspection. LPA, in the company of Director, toured the interior & exterior of the CCC. The CCC operates Monday-Friday from 7:30am-5:30pm. The CCC uses one (1) classroom for infant care purposes. At the time of the inspection, LPA observed eight (8) infants under the care & supervision of three (3) staff members (cleared & associated).

The CCC is clean and orderly. LPA observed required licensing forms and documents posted prominently at the CCC. LPA also observed the daily schedule posted prominently in the classroom. LPA notes the CCC utilizes paper Sign In/Out forms. LPA notes the forms contain the arrival and departure times of infants in care and well as the signatures of the infants' authorized representatives. The classroom has age-appropriate equipment and furnishings available to infants in care. LPA observed disinfectants, cleaning solutions, sharps, and other hazardous items stored in areas inaccessible to infants in care. Medications in the CCC are stored in an area inaccessible to infants, and a refrigerator in the classroom is used to store individually labeled bottles for infants in care. Director advised LPA that milk & formula is provided by the parents of infants in care. LPA observed a first aid kit available in the CCC. LPA observed a smoke detector, fire suppression system, and carbon monoxide detector in the CCC. The carbon monoxide detector was tested at 11:44am and found operational.

(CONT. 809-C, Page 2)

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Seena Parsapour
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2026
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 06/12/2026 04:02 PM - It Cannot Be Edited


Created By: Seena Parsapour On 06/12/2026 at 02:39 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SIMI VALLEY MONTESSORI SCHOOL - WEST VALLEY
FACILITY NUMBER: 566216042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101438.3(c)(1)
Indoor Activity Space For Infants
(1) The sleeping area for infants shall be physically separate from the indoor activity space. This separation shall be accomplished as specified in (b) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that cribs were located against the wall of the indoor activity space, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Licensee shall submit to the Department (seena.parsapour@dss.ca.gov) a written statement explaining how they plan on ensuring compliance moving forward, no later than 6/22/2026. Director advised LPA they will consult the owner to develop a plan and submit Plan of Correction.
Type B
Section Cited
CCR
101439(h)(4)
Infant Care Center Fixtures, Furniture, Equipment and Supplies
(h) Infant changing tables shall: (4) While in use, be placed within arm's reach of a sink.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the changing station was not within arm’s reach of an island sink inside the classroom, and was located against a perpendicular wall on the opposite side of the entry door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Licensee shall submit to the Department (seena.parsapour@dss.ca.gov) a written statement explaining how they plan on ensuring compliance moving forward, no later than 6/22/2026. Director advised LPA they will consult the owner to develop a plan and submit Plan of Correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Maria Mueller
NAME OF LICENSING PROGRAM MANAGER:
Seena Parsapour
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIMI VALLEY MONTESSORI SCHOOL - WEST VALLEY
FACILITY NUMBER: 566216042
VISIT DATE: 06/12/2026
NARRATIVE
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One (1) changing station for infants in care was observed in the infant classroom. At 11:57am, LPA observed that the changing station was not within arm’s reach of an island sink inside the classroom, and was located against a perpendicular wall on the opposite side of the entry door. LPA observed 15-minute safe sleep check logs being completed & maintained on file. At 12:00pm, LPA observed that cribs were located against the wall of the indoor activity space. LPA explained to Director that the sleeping area for infants shall be physically separate from the indoor activity space, and Director confirmed their understanding of this regulation. LPA notes that at 12:43pm, a smoke alarm located in Classroom #03 (for the Preschool license, facility# 566216043) activated. LPA observed Director evacuate infants & preschool-aged children to the outdoor areas where shade was available by umbrellas and a tree. LPA observed the Simi Valley Fire Department arrive & clear the building for re-occupancy at approximately 1:30pm, at which point the inspection resumed.

The CCC uses filtered drinking water (using Brita filters) as well as bottled jugs of drinking water (Pure Life brand) for consumption/food preparation for infants in care. Director advised LPA the outdoor area is not being used for infants in care. LPA notes the outdoor play area is fully enclosed. LPA observed the entry/exit points to be secured. LPA observed age-appropriate toys & play equipment in the outdoor play area. The play equipment is free of sharp, loose or pointed objects. LPA notes that shade is available in the outdoor play area. LPA reminded Director that outdoor play equipment and furnishings should be replaced when such items begin to degrade or are no longer in good repair. No bodies of water were observed on site.

LPA reviewed a sampling of four (4) infants’ records of the infants present at the time of the inspection. The infants’ records reviewed were found to be current & complete. LPA reviewed staff records which were found to be current & complete as well. LPA notes the most recent fire/disaster drill occurred today’s date, 6/12/2026. The CCC maintains a current facility roster listing infants in care. No firearms or ammunition are stored on site.

This facility does not currently provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed infants’, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/. (CONT. 809-C, Page 3)

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Seena Parsapour
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIMI VALLEY MONTESSORI SCHOOL - WEST VALLEY
FACILITY NUMBER: 566216042
VISIT DATE: 06/12/2026
NARRATIVE
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CCCs constructed before January 1, 2010, are required to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in HSC section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, or if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During today’s inspection, two (2) Type B deficiencies are being issued per Title 22 of the California Code of Regulations (See LIC809-D). Director was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.

A notice of site visit was given and must remain posted for 30 days or a $100 civil penalty may apply. Exit interview conducted and report was reviewed with Director Grace Peiris.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Seena Parsapour
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
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