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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407586
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:34:59 PM

Document Has Been Signed on 08/29/2024 12:34 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MONTESSORI OF CHATSWORTHFACILITY NUMBER:
197407586
ADMINISTRATOR/
DIRECTOR:		ERBE, ANNEROSEFACILITY TYPE:
850
ADDRESS:10616 ANDORA AVE.TELEPHONE:
(818) 709-2980
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 110TOTAL ENROLLED CHILDREN: 110CENSUS: 31DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Annerose Erbe, DirectorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 08/29/2024 at 08:30 AM, Licensing Program Analysts (LPAs) Elicia Calvillo and Amelia Morales conducted a Case Management Deficiencies Visit. LPAs identified self and met with Sabrina Mundel, Assistant Director, who allowed entry into the facility and provided LPAs a guided tour of the inside and outside of the facility Upon arrival there were 31 children and 6 staff present, Annerose Erbe, Director arrived shortly after.

During today's visit, LPA's obtained Director's disclosure that they heard Staff #4 yelling “line up” at a child and when the child did not listen right away, Staff #4 went to child and took their hand and strongly pulled them into the line. Director stated that they immediately addressed the concern with Staff #4 and as a result, Staff #4 received a disciplinary warning for this incident.

LPA's informed Director that upon an unusual incident occurrence needs to be reported to the Department. A report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report shall be submitted to the Department within seven days following the occurrence of such event.

As a result of today's visit, the following deficiency listed on the attached deficiency page is being cited in accordance with California Code of Regulations Title 22. A Type B, deficiency was issued for regulation 101212 (d) Reporting Requirements and a Plan of Correction is due xx/xx/xxxx.
The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Annerose Erbe, Director including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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 08/29/2024 12:34 PM - It Cannot Be Edited


Created By: Elicia Calvillo On 08/29/2024 at 11:47 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MONTESSORI OF CHATSWORTH
FACILITY NUMBER: 197407586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
101212(d)

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Reporting Requirements (d) Upon the occurrence, … a report shall be made to,,, by telephone or fax .... In addition, a written report … shall be submitted to the Department within seven days following the occurrence of such event. This requirement is not met as eveidenced by:
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Per Director, at the next staff meeting they will reviiew reporting unusual incidents to the Department and provide LPA a copy of the meeting agenda and sign in sheet. By the plan of correction due date of 09/26/2024.
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Observation, record review, and interviews conducted in that an unusual incident occured at the facility and was not reported to the Department which poses an potential health, safety or personal rights risk to persons in care.
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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:Rita Ramos
LICENSING EVALUATOR NAME:Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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