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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210354
Report Date: 03/14/2022
Date Signed: 03/14/2022 02:37:48 PM

Document Has Been Signed on 03/14/2022 02:37 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: 172CENSUS: 0DATE:
03/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sid LeckTIME COMPLETED:
03:00 PM
NARRATIVE
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On 03/14/2022 at 12:45pm Licensing Program Analysts (LPAs) Ashley Curry and Christina Watts 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) was left in the classroom unattended for less than two minutes. LPAs conducted interviews and obtained relevant documents. A staff member found the child sitting on the floor unattended in the classroom, while the other staff and children were at the play yard. Since this is the second incident at the facility where there was a lack of supervision within 4 months, this poses an immediate risk to the health and safety of the child. A type A citation will be issued. (Please see 809D)

LPA informed facility representative that this report dated 03/14/2022 documents 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA A. Curry informed the facility representative to provide a copy of this licensing report dated 03/14/2022 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 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: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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Document Has Been Signed on 03/14/2022 02:37 PM - It Cannot Be Edited


Created By: Ashley Curry On 03/14/2022 at 01:59 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: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited
CCR
101229(a)(1)

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101229Responsibility 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.
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SInce the incident, facility has implented a new producure to account for all children before they proceed to the play area. While waiting to be called to go outside, the children sit at their desk, so they are more visible to the staff.
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The requirement is not met as evidence by:

Based on interviews and record review the licensee did not ensure that a child was not left without supervison of a teacher at any time.
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By 03/15/2022 provide a written statement detailing the changes that were implemented and any future changes to ensure no child will be left unattended.

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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.
SUPERVISOR'S NAME:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


LIC809 (FAS) - (06/04)
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