<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750091
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:57:34 PM

Document Has Been Signed on 02/24/2022 04:57 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GUIDEPOST MONTESSORI AT PLUM CANYONFACILITY NUMBER:
197750091
ADMINISTRATOR:AARON BAILEYFACILITY TYPE:
830
ADDRESS:19141 SKYLINE RANCH RDTELEPHONE:
9493542259
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 42TOTAL ENROLLED CHILDREN: 42CENSUS: 31DATE:
02/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gina Castello, Head of SchoolTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 24, 2022, Licensing Program Analysts (LPAs) Monique Ayala and Liana Stepanyan conducted a case management inspection to follow up on an Unusual Incident reported to the department in person on 02/24/2022; this incident was not reported timely, the incident occurred on 12/22/2021. LPAs was greeted by head of school who guided LPAs on a tour of the facility. Upon arrival, there were 31 children and 15 staff present today.

Description of the incident: An incident on 12/22/2021, Child 1 (C1) was playing in the playground and tripped over the wooden logs that are used as a barrier. Staff 1 (S1) stated she saw when C1's hit her head on the wooden log and began to consult C1. S1 stated she asked for support from other staff to bring S1 an ice pack for C1. C1 was brought into the office where C1's mother was called and was informed of the incident. Assistant Head of School stated that C1's mother asked that C1 not to nap due to head injury. C1's mother picked C1 up from facility. C1 did not receive any medical attention. C1 did have a bruise and a bump on center forehead that was a result from hitting her head on wooden log. (Staff and child names are listed on LIC859 and LIC857, confidential.)

During this inspection, LPA interviewed head of school, staff, parent of C1, obtained pictures of where the incident occurred, obtained images of injury and obtained a copy of the facility roster.

The information obtained during interviews conducted revealed that S1 was in close proximity to the incident and there was no form of lack of supervision. The incident occurred very fast and staff was not able to prevent the accident. The facility staff took the appropriate measures following the incident as they applied first aid, contacted C1’s parent.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: GUIDEPOST MONTESSORI AT PLUM CANYON
FACILITY NUMBER: 197750091
VISIT DATE: 02/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Head of school was reminded of reporting requirements for unusual incident reports that occur at the facility.

A type B deficiency is being cited today in accordance with Title 22 Regulation, Reporting Requirements 101212(d)(1)(2).

An exit interview was conducted, a copy of this report was provided along with Notice of Site Visit and Appeal Rights to Head of School.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/24/2022 04:57 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 02/24/2022 at 04:17 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GUIDEPOST MONTESSORI AT PLUM CANYON
FACILITY NUMBER: 197750091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
101212(d)(1)(2)

1
2
3
4
5
6
7
Reporting Requirement: Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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.
1
2
3
4
5
6
7
Head of school, stated she will report incident reports during working hours.
8
9
10
11
12
13
14
In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. This requirement was not met as evidence by: Based on observation, interivew and record review, facility did not file incident report in timely manner.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Mariela Ramon
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3