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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420951
Report Date: 11/07/2023
Date Signed: 11/07/2023 10:58:33 AM

Document Has Been Signed on 11/07/2023 10:58 AM - 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:GLOBAL MONTESSORI INTERNATIONAL SCHOOLFACILITY NUMBER:
013420951
ADMINISTRATOR:TENG, VIVIFACILITY TYPE:
850
ADDRESS:2830 - 9TH STTELEPHONE:
(510) 845-6969
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 37DATE:
11/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Elisha HernandezTIME COMPLETED:
11:07 AM
NARRATIVE
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On November 7, 2023 at 9:06am, 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 November 2, 2023. LPA conducted a tour for a health and safety inspection. There were 37 children and 9 staff present during today's visit.

The unusual incident involved a child who ran out of a classroom and into the play yard. LPA conducted staff interviews which indicated that a child ran out of a class when the teachers were attempting to comfort a crying child. This resulted in a child being left alone for approximately 5 minutes.

There will be a Type A citation issued for the incident. LPA informed Administrative staff Elisha Hernandez to post and provide a copy of this licensing report dated November 7, 2023 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 next 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in the child's file for verification.

Exit Interview conducted.
Report and Appeal Rights reviewed and provided to Administrative staff Elisha Hernandez.
The Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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 11/07/2023 10:58 AM - It Cannot Be Edited


Created By: Indira Loza On 11/07/2023 at 10:39 AM
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: GLOBAL MONTESSORI INTERNATIONAL SCHOOL
FACILITY NUMBER: 013420951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2023
Section Cited
CCR
101229(a)(1)

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(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...(1). Supervision shall include visual observation. This requirement was not met as evidenced by:
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The Director shall come up a plan to ensure that all children will be under 100% supervision at all times. This plan must be emailed to LPA no later than the Close of Business on Nevember 8, 2023.
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Based on record review and interviews it was determined that a child was able to leave to the playground and was unsupervised for approximately 5 minutes, which poses an immediate risk to the health, safety, and personal rights 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: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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