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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405005
Report Date: 06/22/2021
Date Signed: 06/23/2021 02:37:46 PM

Document Has Been Signed on 06/23/2021 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:A LITTLE WORLD MONTESSORI ACADEMYFACILITY NUMBER:
073405005
ADMINISTRATOR:SAMUDRA DE ALWISFACILITY TYPE:
850
ADDRESS:355 PARKER AVETELEPHONE:
(510) 799-6361
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 34TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Samudra De AlwisTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Annual Required inspection. There were 2 staff and 2 children present during the inspection. Furniture was observed to be in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were inaccessible during the visit. The toilets and sinks were in operable condition. The floors were free of tripping hazards. The kitchen/food preparation and storage areas were observed to be clean. Food is protected against contamination. All storage containers for solid waste have tight-fitting covers that are in good repair. Drinking water is available both indoors and outdoors. Menus are posted. The facility serves snack only. The children bring their lunches from home. Director was reminded to have food on hand in case a child does not bring a lunch. Climbing equipment is properly anchored to the ground with adequate and appropriate cushioning material to absorb falls. There is a shaded area provided for the children

The facility is operating within its licensed capacity. The facility is within ratio today with one teacher supervising no more than 12 children. LPA did not observe any child left without visual supervision or unattended during the inspection. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility as stated by the director. LPA verified both opening and closing staff have current CPR/First aid training. A physical census was taken of all children present and crossed referenced with the sign in and out sheets.

A sample of children’s records were reviewed. Files reviewed contained emergency information and health assessments. Staff records reviewed have required health screening.
Fire/Disaster drill are conducted at least once every six months.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2021
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 06/23/2021 02:37 PM - It Cannot Be Edited


Created By: Cherie Acosta On 06/22/2021 at 03:14 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: A LITTLE WORLD MONTESSORI ACADEMY
FACILITY NUMBER: 073405005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2021
Section Cited
HSC
1596.7995(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Director shall ensure all staff have of proof of required immunizations in their file. Director shall submit a self certified letter to CCL by 7/20/21
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This requirement was not met as evidenced by: Staff present did not have proof of required immunizations which poses a potential risk to the health and safety of children in care
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• Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected

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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Cherie Acosta
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021


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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: A LITTLE WORLD MONTESSORI ACADEMY
FACILITY NUMBER: 073405005
VISIT DATE: 06/22/2021
NARRATIVE
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The director understands that prior to working or volunteering in a licensed child care facility, all individuals subject to criminal record review shall obtain a clearance or criminal record exemption.

The director was encouraged to email ChildCareAdvocatesProgram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

The following deficiency was observed during the inspection:

At approximately 2:30pm during file review LPA observed that staff present did not have proof of required immunization.

See 809-D for deficiency cited under California Code of Regulations, title 22

An exit interview was conducted with Samudra De Alwis.
Director was provided a copy the appeal rights.
A Notice of Site visit was provided at the time of inspection and must be posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC809 (FAS) - (06/04)
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