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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417509
Report Date: 12/13/2024
Date Signed: 12/13/2024 04:42:48 PM

Document Has Been Signed on 12/13/2024 04:42 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:LITTLE ELEPHANT MONTESSORIFACILITY NUMBER:
013417509
ADMINISTRATOR/
DIRECTOR:		NATANYA MOOREFACILITY TYPE:
850
ADDRESS:5782 MILES AVENUETELEPHONE:
(510) 597-1963
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY: 33TOTAL ENROLLED CHILDREN: 33CENSUS: 27DATE:
12/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Natanya MooreTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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On December 13, 2024 at 2:20pm Licensing Program Analyst (LPA) Indira Loza arrived at the facility for an unannounced visit as a direct result of an Unusual Incident Report received in the Oakland Regional Office on September 3, 2024. Present during today's visit were 27 preschoolers and 4 fingerprint cleared staff. LPA toured the facility for a Health and Safety check.

The unusual incident involved a child with a sesame allergy who was served a snack containing humus. Staff interviews revealed that there is one staff person who plans the snack menu, does the food shopping, and serves the snacks. The staff person did not know that humus contains sesame seeds. California Code of Regulations Title 22 101227(a)(7)(B) is being cited with one Type B deficiency.

See LIC809-D for one Type B citation.

Exit Interview conducted.
Report and appeal rights provided to Director Natanya Moore.
Notice of Site visit must be posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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 12/13/2024 04:42 PM - It Cannot Be Edited


Created By: Indira Loza On 12/13/2024 at 03:41 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: LITTLE ELEPHANT MONTESSORI
FACILITY NUMBER: 013417509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
101227(a)(7)(B)

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Food Services: (a) In child care centers providing meals to children, the following shall apply: (7) Modified diets prescribed by a child's physician as a medical necessity shall be provided. (B) A child shall not be served any food to which the child's record indicates he/she has an allergy.
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The Director shall come up with a plan detailing how they will prevent the children from being served foods that contain a food allergen. This plan shall be submitted to the LPA no later than December 27, 2024 by close of business.
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This requirement was not as evidenced by: Based on records reviewed and interviews conducted it was determined that the facility served food that contained a known allergen. This poses a potential health, safety, and personal rights risk to children in care.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2024


LIC809 (FAS) - (06/04)
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