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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408897
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:24:17 PM

Document Has Been Signed on 06/14/2023 02:24 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: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: 109CENSUS: 41DATE:
06/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sumaira RizviTIME COMPLETED:
03:00 PM
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On 6/14/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at Fountainhead Montessori School Pleasant Hill. LPA met with Director, Sumaira Rizvi and explained purpose of inspection.

On 3/7/23 a child C1 fell in the outdoor playground and got a head injury which required medical treatment. Facility self reported the incident on 3/10/23 after becoming aware of medical intervention. During today's investigation, LPA conducted interviews, inspected the outdoor play ground and obtained relevant information and documents. This incident NEEDS FURTHER INVESTIGATION.

Facility is operating a Summer Camp and there were 41 children present during inspection. No deficiency was cited today. This report was reviewed with Director, Sumaira Rizvi. NOTICE OF SITE VISIT WAS ISSUED, MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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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