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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412388
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:02:42 PM


Document Has Been Signed on 07/14/2022 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MONTESSORI SCHOOL OF CENTERVILLEFACILITY NUMBER:
013412388
ADMINISTRATOR:MATICHAK, LYSAFACILITY TYPE:
850
ADDRESS:4209 BAINE AVENUETELEPHONE:
(510) 797-9944
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:85CENSUS: 31DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Lysa MatichakTIME COMPLETED:
04:05 PM
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On July 14, 2022 at approximately 10:40am Licensing Program Analyst (LPA) Russ Haderer arrived unannounced to conduct and annual site inspection and met with Site Director Lysa Matichak. Present at arrival was 22 preschool children (age early 4 to 5) and 9 toddlers (age 18 to 36 months) and 2 teaches and an office staff. All adults present are background cleared and associated to the facility. The hours of operation are 7:00am to 6:00pm.

There are 2 separate buildings on the site. The main building has 3 administration offices, a staff toilet, a kitchen, 2 separate classrooms, 2 children’s bathrooms with 4 toilets and 4 sinks. The second building has 2 classrooms, an office with a staff bathroom, small kitchenette, and 2 children’s bathrooms with a total of 4 toilets and 4 sinks. The bathrooms have appropriate hand washing signage and there are enough hand towels and soap. All toilets, handwashing and cleaning areas are in safe and sanitary operating condition.

The outside has two large play areas, and an area with picnic tables. All play equipment is in safe condition and free from sharp, loose, or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Shade was available in the play areas and teachers are always be present.
The facility has a fully charged 2A10BC fire extinguishers in each building. Fremont Fire Department began their annual fire inspection on March 31, 2022. One alarm bell was replaced, and fire extinguishers were recharged on April 6, 2022. Final fire inspection was completed and passed on June 28, 2022. There are working smoke and carbon monoxide detectors (tested and working). Heating and ventilation are acceptable. Disaster drills (earthquake and fire) are conducted monthly. The last drill was conducted on July 8, 2022.

The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. There were no hazardous items/toxins observed to be accessible to children in care today. There are no bodies of water accessible to children in care.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MONTESSORI SCHOOL OF CENTERVILLE
FACILITY NUMBER: 013412388
VISIT DATE: 07/14/2022
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The school provides breakfast, hot lunches (from Fremont Unified School District) and afternoon snacks, all menus are posted. Children bring in their own food for any special requirements or preferences. There is an outside drinking fountain that is not in use at this time, however, children bring their own water bottles and water is also available if they forgot theirs or have run out. Food stocks in the kitchen were checked for expiration dates (frozen and refrigerated foods were also checked) and found to be acceptable.

Napping cots are available for children that need to sleep and items for sleeping are labeled with their names in cubbies. All classrooms have cubbies for children’s personal belongings (including the bedding for napping cots), personal items do not come into contact with other personal items. The center was monitoring infant children napping but not physically recording the sleep checks. LPA provided guidance and a sample to use from this day forward for all children under the age of 24 months.

The school uses manual sign in/out sheets with clean pen bins and used pen bins. The sign-in/sign-out notebooks are on a table near the entrance gate. Counts were checked and accurate. Covid protocol is followed (temperatures measured, hand washing (or sanitizer used) upon entry, children and staff are encouraged wear face coverings whenever indoors. All classrooms have windows and good cross ventilation.

The facility has two children that require incidental medication (EpiPen’s). Signed parent consent forms (LIC9112) and medical Plan of Action were present.

At approximately 1:00pm LPA reviewed children's files: LPA requested and reviewed facility roster. Three of 10 files checked were missing the LIC701 Physician’s Report and one child’s file was missing the signed LIC613A Personal Right’s form. See LIC809D for deficiencies.

At approximately 1:55 pm LPA performed staff file review. All staff subjected to criminal review have been cleared and associated to the facility. All files were complete, up to date and found to be in compliance with Title 22 regulations.
Site Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MONTESSORI SCHOOL OF CENTERVILLE
FACILITY NUMBER: 013412388
VISIT DATE: 07/14/2022
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LPA discussed the safe sleep regulations with Site 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 Site 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

There were 2 deficiencies found today, see LIC809D for details. This report will remain on file for three years.

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

Exit interview conducted and report was reviewed with the Site Director Lysa Matichak.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/14/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MONTESSORI SCHOOL OF CENTERVILLE
FACILITY NUMBER: 013412388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 3 of the 10 children's files examined did not have an LIC701 Physician's Report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Site Director to collect the LIC701 Physician's Report for these three children and in addition, complete an inventory of all children's files to ensure completeness.
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one child's file was missing the signed receipt of the LIC613A form Personal Rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Site Director will obtain the signature on the form and retain the bottom portion of the document in the child's file.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5