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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412618
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:20:59 PM

Document Has Been Signed on 12/13/2023 02:20 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:MONTESSORI CHILDREN'S CENTERFACILITY NUMBER:
013412618
ADMINISTRATOR:SALVADOR, LULETTEFACILITY TYPE:
850
ADDRESS:33170 LAKE MEAD DRIVETELEPHONE:
(510) 489-7510
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 110TOTAL ENROLLED CHILDREN: 49CENSUS: 45DATE:
12/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Lulette SalvadorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 12/13/2023 Licensing Program Analyst (LPA) Jaleesa Jackson conducted an unannounced case management visit. LPA met with Director Lulette Salvador. Present for the inspection was 6 staff and 45 preschool age children in care.

During record reviews and interviews, the facility did not report to the Department unusual incidents 24 hours after they occurred. LPA asked if parent of C1 was notified of the incident and she was unsure since the prior Director was still in charge. LPA informed Director that the parents of C1 need to be notified if they haven't been already. LPA reviewed the reporting requirements regulation with Director.

See 809-D for deficiencies cited during today's inspection.

Exit interview conducted with Lulette Salvador and appeal rights provided.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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 12/13/2023 02:20 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 12/13/2023 at 12:03 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 CHILDREN'S CENTER
FACILITY NUMBER: 013412618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2024
Section Cited
CCR
101212

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 Reporting Requirements 101212 (d)(1)(C) ... report shall be made to the Department by telephone or fax within the Department's next working day... Events reported shall include the following: Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Director will have an all staff meeting which will include watching the video on the CCLD website for reporting requirments. Director will send the sign in sheet of staff present and the meeting agenda showing that the video was reviewed to LPA by email by POC date.
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This requirement was not met as evidenced by:
Based on interview and record review, Director did not notify department of child's personal rights being violated which poses a potential risk to the children's health and safety.
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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:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
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