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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408897
Report Date: 04/10/2023
Date Signed: 04/10/2023 11:34:03 AM

Document Has Been Signed on 04/10/2023 11:34 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:FOUNTAINHEAD MONTESSORI SCHOOL-PLEASANT HILLFACILITY NUMBER:
073408897
ADMINISTRATOR:RIZVI, SUMAIRAFACILITY TYPE:
850
ADDRESS:1715 OAK PARK BOULEVARDTELEPHONE:
(925) 967-2655
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 99TOTAL ENROLLED CHILDREN: 99CENSUS: 78DATE:
04/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sumaira RozviTIME COMPLETED:
11:45 AM
NARRATIVE
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On 4/10/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at Fountainhead Montessori School and met with Director, Sumaira Rizvi.

On 3/31/23 Center reported to Licensing Office an incident involving two children who were left alone inside Lake classroom without visual supervision. Today 4/10/23 during investigation, LPA conducted interviews and facility walk through. It was determined that on 3/30/23 after nap time Staff S1 took two children C1 and C2 back to Lake classroom. No one was in the room at the time. S1 left C1, C2 by themselves, closed the front door and left the room without handing them over to another staff person. At that time Staff S2 and few children were in the play ground located outside the classroom. S2 saw C1 and C2 open the yard door from the room and walk out into the play yard. S2 did not see C1, C2 being dropped off in the room or observe any staff person with them when they walked into the yard. C1 and C2 were without visual supervision for some time however it could not be determined how long they were alone in the room before walking out to the play yard. Director and S2 estimate they were alone for few seconds. S1 does not work at the center anymore and Director states she has discussed supervision with all staff and continues to remind them about visual supervision.

Since children were left alone in a room without 100% visual supervision, there was absence of supervision and this posed an immediate risk to health and safety of children in care. Type A deficiency is cited on page 809D. LPA reminded Director that under California Code of Regulations Title 22 centers are required to provide 100% visual supervision to children at all times.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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 04/10/2023 11:34 AM - It Cannot Be Edited


Created By: Monica Mathur On 04/10/2023 at 10:46 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: FOUNTAINHEAD MONTESSORI SCHOOL-PLEASANT HILL
FACILITY NUMBER: 073408897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/11/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care & Supervision (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. Supervision shall include visual observation. This requirement is not met as evidenced by:
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By POC Due Date 4/11/23 Director agreed to:1 Send written plan how center will be in compliance moving forward.
By Due Date 4/17/23 hold all staff meeting, discuss plan, regulations, watch training video on www.ccld.ca.gov. Send agenda/attendance verification to CCLD by end of 4/17/23.
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Per investigation, S1 left C1, C2 in Lake room alone. There was no one in the room and S1 did not hand them over to a staff person. This posed an immediate risk to safety of children.
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Provide a copy of this licensing report to parents/guardians of all children currently enrolled and to any newly enrolled parents/guardians for 12 months. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) must be placed in the child's file

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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:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


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: FOUNTAINHEAD MONTESSORI SCHOOL-PLEASANT HILL
FACILITY NUMBER: 073408897
VISIT DATE: 04/10/2023
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LPA Mathur informed Director, Sumaira Rizvi this report dated 4/10/23 with 1 Type A citation shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. LPA Mathur informed Director to provide a copy of this licensing report that documents any Type A citation(s) 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 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

This report was reviewed with Director, Sumaira Rizvi. NOTICE OF VISIT WAS ISSUED, MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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