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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019814
Report Date: 03/07/2023
Date Signed: 03/07/2023 06:26:50 PM

Document Has Been Signed on 03/07/2023 06:26 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PRIMANTI MONTESSORI ACADEMYFACILITY NUMBER:
198019814
ADMINISTRATOR:HISSANKA GUNASEKARAFACILITY TYPE:
850
ADDRESS:10947 VALLEY HOME AVETELEPHONE:
(562) 943-0246
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 124TOTAL ENROLLED CHILDREN: 42CENSUS: 92DATE:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Mary Beth Peralta DirectorTIME COMPLETED:
06:45 PM
NARRATIVE
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On 3/7/23 Licensing Program Analysts (LPAs) Lilli Babcock and Mary Silva visited the facility to conduct a complaint inspection for the infant and preschool licenses. A COVID risk assessment was conducted, and appropriate PPE was used by LPA.

Upon arrival, Director, Mary Beth Peralta guided analysts on a tour of the infant and preschool classrooms. LPAs observed Staff #11 (S11), Staff #12(S12) and Staff #14 (S14) in the Preschool Room were not associated to the facility and were not on the Guardian Facility Roster. Director stated she had mailed the association documents to the Regional Office (RO), but stated she did not call the RO to confirm they had been processed.

Based on the LPAs observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.



LPA Lilli Babcock informed facility representative, Mary Beth Peralta that this report dated 3/7/23 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Lilli Babcock informed the facility representative to provide a copy of this licensing report dated 3/7/23 that documents any Type A citation 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

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Lilli Babcock
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PRIMANTI MONTESSORI ACADEMY
FACILITY NUMBER: 198019814
VISIT DATE: 03/07/2023
NARRATIVE
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statement, must be placed in the child's file for verification.

A Notice of Site Visit (LIC 9213) was give to the Director and must remain posted for 30 days during the hours of operation after the visit by a licensing representative.

Exit interview conducted and report was reviewed with Director, Mary Beth Peralta.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Lilli Babcock
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/07/2023 06:26 PM - It Cannot Be Edited


Created By: Lilli Babcock On 03/07/2023 at 05:08 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PRIMANTI MONTESSORI ACADEMY
FACILITY NUMBER: 198019814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2023
Section Cited
CCR
101170(e)(2)

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All individuals subject to a criminal record review shall prior to working... in a licensed facility...Request a transfer of a criminal record clearance as specified in Section 101170(f)
This requirement was not met as evidenced by:
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Director gave copies of clearance transfer to LPA for processing.
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Based on observation, interview and record review, 3 of 9 staff present in Preschool Rooms had no fingerprint clearance transfered to facility, which poses an immediate health and safety risk to children 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Lilli Babcock
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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