<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210354
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:38:31 PM

Document Has Been Signed on 02/04/2022 03:38 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:GRAND LAKE MONTESSORIFACILITY NUMBER:
010210354
ADMINISTRATOR:FAYE OWENSFACILITY TYPE:
850
ADDRESS:466 CHETWOOD STTELEPHONE:
(510) 836-4313
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 172TOTAL ENROLLED CHILDREN: 114CENSUS: 71DATE:
02/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sid LeckTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/04/2022 at 2:00pm Licensing Program Analysts (LPAs) Ashley Curry and Monica Mathur conducted an unannounced Case Management inspection at Grand Lake Montessori. LPAs met with the administrator Sid Leck and explained the purpose of today's inspection. The facility self reported an unusual incident where a child (C1) left with another parent during pick up time. LPAs conducted interviews, inspected the facility premises, and obtained relevant documents. The parent noticed the child was with them outside of the second gate. The child was never alone and there were many other parents outside. Child was brought back to supervising staff by a parent in less than 1 minute. The staff was unaware the child have left. There was a lack of supervision, which resulted in a potential risk to the health and safety of the child. Type B deficiency was issued (Please see 809D).

Exit interview was conducted, appeal rights were given, and report reviewed with facility representative Sid Leck.

Notice of site visit issued and must be posted for 30 days.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/04/2022 03:38 PM - It Cannot Be Edited


Created By: Ashley Curry On 02/04/2022 at 02:59 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GRAND LAKE MONTESSORI
FACILITY NUMBER: 010210354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation.
This requirement was met as evidence by:
1
2
3
4
5
6
7
Facility installed a second gate to keep children inside the deck closer to the room.
Submit a written plan of changes that were implemented or will be implemented to ensure all staff have 100% supervision of children at all times.

8
9
10
11
12
13
14
Based on observation and interviews there was a lack of supervision which resulted in a child leaving the premises with another parent. Child was never alone and was returned within 1 minute. This posed a potential risk to the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14
Conduct a staff training on supervision. Watch videos on supervision and personal rights at www.ccld.ca.gov

Please submit written plan and confirmation of training to LPA.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2