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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408897
Report Date: 06/21/2023
Date Signed: 06/21/2023 04:18:24 PM

Document Has Been Signed on 06/21/2023 04:18 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: 110CENSUS: 50DATE:
06/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sumaira RizviTIME COMPLETED:
04:45 PM
NARRATIVE
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On 6/21/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at Fountainhead Montessori School Pleasant Hill. LPA met with Director, Sumaira Rizvi. Today's visit is a follow up on the Case Management inspection of 6/14/21.

During today's inspection, LPA observed supervision of children during outdoor activity and conducted interviews. This is a follow up investigation of an incident where a child C1 fell and sustained head injury during outdoor play that required medical attention. Incident occurred on 3/7/23 and facility self reported the incident to Licensing Office.

Evidence and information gathered through facility inspection, observations, interviews and documents determined that on 3/7/23 two children C1, C2 were playing with a short basketball hoop that moved on wheels. Both children were standing inside the hoop, walking and wobbling with it in the area between structure and concrete wall. C1, C2 lost their balance and fell. C1 hit back of head on concrete wall and sustained a cut. There were two staff S1, S2 present. S2 was positioned near the classroom door on the other side of play structure, did not visually see the incident happen. S2 was alerted after hearing C1 crying, went around the play structure and saw C1 holding head. Few minutes later S3 arrived in the playground and observed S1, S2, sitting with C1. S3 and Director helped C1 after S3 noticed the injury bleeding. First aid was provided and parents were informed.

Director stated S1 does not work at the center anymore. When she spoke to S1 after the incident, S1 told her she was talking to a parent who was dropping off a child and saw the incident. S2 was on the other side of the play structure which prevented her from observing the incident, did not have a visual of C1, C2, did not see the incident occur. Director stated the hoop has been removed from use since the incident.

continued on 809-C

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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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: 06/21/2023
NARRATIVE
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Contradicting S1's claim to Director, C1 and C2 stated teachers were not looking. C1’s parent P1 stated when she spoke to S1, she said she did not see the incident happen, was not sure how it happened and tried to deflect blame. LPA interviewed S3 who stated S1, S2 told her they both did not see how incident happened. Parent and staff confirmed the wound bled on and off over next couple days. When bleeding did not subside next day, C1 was taken to the hospital and received stitches.

Information and evidence obtained shows lack of supervision, staff failed to notice children in imminent danger playing inside a potentially risky/unstable piece of equipment and being in a situation that could result in an accident/injury. Staff failed to provide active visual supervision and unaware when and how incident occurred.

Lack of supervision, failing to prevent dangerous situation resulting in child's head injury that required stitches, medical attention and failure to provide active 100% visual supervision posed an immediate risk to health and safety of children in care. Type A deficiency is cited on 809D page of report. This is a repeat violation under same regulation within 12 months and civil penalty of $250 is assessed today. A Non Compliance Conference will be scheduled with Regional Office to discuss deficiencies.

LPA discussed and provided technical assistance on changes and improvements that need to be made immediately with outdoor staff supervision such as positioning additional staff, reducing activity area used by cordoning off, staff refrain from chatting/talking to each other and parents unless absolutely necessary, actively walking around, visually cover blind spots and distant areas, not having too many children present outside at the same time.

LPA Monica Mathur informed that this report dated 6/21/23 with 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Mathur informed the Director Sumaira Rizvi to provide a copy of this licensing report dated 6/21/23 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 (LIC 9224), or other written statement, must be placed in the child's file for verification.

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: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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Document Has Been Signed on 06/21/2023 04:18 PM - It Cannot Be Edited


Created By: Monica Mathur On 06/21/2023 at 02:44 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: FOUNTAINHEAD MONTESSORI SCHOOL-PLEASANT HILL
FACILITY NUMBER: 073408897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/29/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and 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 6/29/23 Director agreed to
1. send a written plan of compliance with supervision.
2. By 6/28/23 hold staff training to discuss plan of action.
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Per investigation, on 3/7/23 C1 sustained head injury while playing in outdoor yard.S1,S2 were present but did not visually see incident happen.Lack of supervision resulted in child's head injury that required medical attention and failure to prevent imminent dangerous situation, not provide active 100% visual supervision posed an immediate risk to health and safety of children in care. Repeat violation within 12 months, civil penalty of $250 assessed today.
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Type A report to be POSTED and PROVIDED to all current parents and those enrolling over next 12 months.

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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: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


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