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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213903
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:45:09 PM

Document Has Been Signed on 08/02/2023 03:45 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 AT WASHINGTON AVENUEFACILITY NUMBER:
010213903
ADMINISTRATOR:YOUSSEF, MARIANFACILITY TYPE:
850
ADDRESS:14795 WASHINGTON AVENUETELEPHONE:
(510) 357-8432
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 111TOTAL ENROLLED CHILDREN: 111CENSUS: 57DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Authorized Representative Sarah NasrTIME COMPLETED:
04:00 PM
NARRATIVE
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On Wednesday, August 2, 2023 at 11 am, Licensing Program Analysts (LPAs) Manel Estoesta and Jaleesa Jackson conducted an unannounced inspection related to the Complaint Investigation submitted on 07/28/2023. LPA met with Facilty Authorized Representative Sara and explained the nature of the site visit. The Director Marian "Mira" Youssef is currently on leave of absence.

At 11 am, LPA's observed 4 staff supervising 57 preschool children at the outdoor play area. The Licensee was not in compliance with Teacher to Child Ratio and in violation of CCR 101216.3(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.....

At 12:30 pm, LPA's spoke with the Director Marian "Mira" via phone and LPA's conducted an interview. Mira stated that she received an email on 07/25/2023 from P2 about S1 "hit C1 on C1 face." Mira, P1 and P2 had a discussion on 07/26/2023 about Mira's plan to conduct an internal investigation of the mentioned incident. Facility Staff failed to report the incident which is in violation Section Reporting Requirements 101212 (d)(1)(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.......

Please see LIC 809 D for the Type A and B deficiency, REPEAT VIOLATIONS and Assessed Civil Penalties.

LPAs Estoesta and Jackson informed the Facilty Authorized Representative Sara that this report dated 08/02/2023, with Type A citation, which shall be posted for 30 consecutive days as there was immediate risk(s) to the health, safety, or personal rights of children in care.

SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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 08/02/2023 03:45 PM - It Cannot Be Edited


Created By: Manel Estoesta On 08/02/2023 at 01:08 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: MONTESSORI SCHOOL AT WASHINGTON AVENUE
FACILITY NUMBER: 010213903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
101212(d)(1)(C)

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Section Reporting Requirements 101212 (d)(1)(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child........REPEAT VIOLATION, 2/24/23 first Tyoe B Deficiency.
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The Director will prepare and submit a STAFF meeting agenda to the Regional Office via mail that outlines the following items; 1. Completed LIC 624 UNUSUAL INCIDENT/INJURY REPORT and 2. INCIDENT/INJURY REPORT types......
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Facility Staff failed to report the incident of C1 and S1 mentioned on the email dated 07/25/203 to the Licensing Office which poses a potential risk to the children's health and safety.
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 3. Videos to watch - Parents and Families, and Child Care Center Operators. The Director will submit the attendee’s proof of attendance and POC documenttation should be mailed to Regional Office.

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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:Jason Jang
LICENSING EVALUATOR NAME:Manel Estoesta
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2023 03:45 PM - It Cannot Be Edited


Created By: Manel Estoesta On 08/02/2023 at 01:30 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: MONTESSORI SCHOOL AT WASHINGTON AVENUE
FACILITY NUMBER: 010213903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2023
Section Cited
CCR
101216.3(a)

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(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.......REPEAT VIOLATION, 03/08/2023 1st Violation.
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The Director will create and submit an updated written Staffing Plan to maintain Teacher to Child Ratio to Regional Office which include but not limited to amended Children Staff Roster and Staff Hiring process.
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LPA's Estoesta and Jackson observed at 11 am, 4 staff supervising 57 preschool children which poses an immediate risk to health and safety of children in care.
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 Videos to watch - Parents and Families, and Child Care Center Operators. The Director will submit the attendee’s proof of attendance and POC documenttation should be mailed to Regional Office. The Technical Support Program (TSP) recommendation.

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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:Jason Jang
LICENSING EVALUATOR NAME:Manel Estoesta
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


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 AT WASHINGTON AVENUE
FACILITY NUMBER: 010213903
VISIT DATE: 08/02/2023
NARRATIVE
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Also, LPAs Estoesta and Jackson informed the Facilty Authorized Representative Sara to provide a copy of this licensing report dated 08/02/2023 that document of any 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.

For Licensing Facility Inspection Reports on our Child Care Transparency Website, please follow the links below.
https://cdss.ca.gov/inforesources/community-care-licensing/facility-search-welcome
https://www.ccld.dss.ca.gov/carefacilitysearch/ Completed reports will be uploaded every week (Sunday).

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

Exit interview conducted and report was reviewed with the Facilty Authorized Representative Sara.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC809 (FAS) - (06/04)
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