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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408869
Report Date: 07/05/2023
Date Signed: 07/05/2023 02:47:24 PM

Document Has Been Signed on 07/05/2023 02:47 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:KEYSTONE MONTESSORI SCHOOLFACILITY NUMBER:
073408869
ADMINISTRATOR:PATHAK, ROHINIFACILITY TYPE:
850
ADDRESS:6639 BLAKE STREETTELEPHONE:
(510) 709-5853
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 57TOTAL ENROLLED CHILDREN: 57CENSUS: 42DATE:
07/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:PATHAK, ROHINITIME COMPLETED:
03:00 PM
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THIS REPORT IS AN AMENDED REPORT FROM ORIGINAL REPORT DATED May 24, 2023.

On July 5, 2023 at 2:00 PM Licensing Program Analyst (LPA) Nyeesha Blount conducted an unannounced Unusual/Incident Report follow up.LPA met with Director Pathak, Rohini to discuss the incident that was reported on May 17, 2023 that a parent reported her child stated the teacher hurt her arm, preventing the child from opening the door and running out the classroom. The Director was not present when the incident occurred she was advised from her administrative assistant. Director has sent the teacher home until this situation has been resolved.

There were no deficiencies during today’s visit, exit interview and report reviewed with Director Pathak, Rohini.

Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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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