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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020312
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:12:20 PM

Document Has Been Signed on 10/02/2024 01:12 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:MONTESSORI ACADEMY OF LA PUENTE/W.COVINAFACILITY NUMBER:
198020312
ADMINISTRATOR/
DIRECTOR:		ISMAT ARASTUFACILITY TYPE:
830
ADDRESS:846 N. ORANGE AVETELEPHONE:
(626) 917-3638
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 29TOTAL ENROLLED CHILDREN: 22CENSUS: 14DATE:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Melissa Villareal & Olivia PascuaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 10/2/2024 at 9:00 am, Licensing Program Analyst (LPA) Carolyn Tuba conducted a case management inspection due to an incident that was reported and submitted by the facility on 9/27/2024. Covid Risk assessment was conducted. LPA met with Director, Melissa Villareal. LPA observed and took a census of 14 children with 6 staff. During the course of the visit the Director needed to leave and Assistant Director, Olivia Pascua took over in her absence.

The incident was reported to the Department within the required 24 hours of occurrence.

The incident reported by the facility was that Child #1 (C1) had fallen out of a crib during naptime. LPA interviewed Director, Staff #1 (S1), Staff #2 (S2). LPA was unable to interview C1 due to their age. The following documentation was obtained: Incident report to parent, a copy of 15-minute sleep log, C1’s medical report from the physician, safe sleep and supervision training of staff signatures who attended, document provided to staff of safe sleep procedures.

Based on interviews and Unusual Incident Report (UIR) it was disclosed that on 9/26/2024 at approximately 1:15 pm the side crib door was not properly latched, and C1 pushed open the crib door, which caused C1 to fall out. According to S1 and S2 the child had woken up prior to S2 going to make a bottle for C1. S1 was left in the nap room and C1 stood-up and push the crib door open. S1 attempted to grab C1 prior to falling but was unable to catch C1 in time. C1 bumped forehead onto the floor surface. LPA measured the crib door, and found that it was approximately 17 inches from the crib door to the floor from where C1 fell. LPA took photo of the crib and the new carpet that was placed in the infant nap room as a safety precaution after the incident. According to S1, S2 and the Director they saw no visible injuries, only a small pink mark on C1’s forehead. (Photo of C1 was provided by the Director) S1 and S2 stated that C1 only cried for a few seconds and then stopped. First Aid of an ice pack was provided, and parent was called by the Director right away after the incident occurred. LPA determined that the facility provided proper first aid procedures for C1.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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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: MONTESSORI ACADEMY OF LA PUENTE/W.COVINA
FACILITY NUMBER: 198020312
VISIT DATE: 10/02/2024
NARRATIVE
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Parent picked C1 at around 3:00 pm and sought medical attention on the same day. According to physician’s medical report who evaluated C1, they deemed the child could return to school on 9/27/2024 at full capacity. According to the Director, right after the incident C1 did not have any bumps or bruises and was observed to be acting normally. Director stated that a training for Safe Sleep and procedures for crib use was provided to all infant staff and a Safe Sleep document was provided. LPA determined that C1 had woken up prior to bottle being made. LPA consulted with the Director that should a child wake-up, they should be removed right away them from the crib. Should infant be fed, and fallback asleep then infant may be placed back to sleep. LPA also consulted with Director to make sure that the crib is age appropriate since it is a smaller crib. S2 disclosed that they were instructed that if an infant can stand on their own, they will be placed in the bigger crib and infants younger then 6 months will be placed in the smaller crib. LPA confirmed with the Director who stated that the Infant Director, Yolanda Vela who was not present during today’s visit may have given those instructions.

Based on staff interviews, records review a deficiency is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D for citation.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Assistant Director, Olivia Pascua.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/02/2024 01:12 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 10/02/2024 at 11:41 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MONTESSORI ACADEMY OF LA PUENTE/W.COVINA
FACILITY NUMBER: 198020312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
101630(1)

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(1) No child shall be forced to sleep, to stay awake or to stay in the napping area. This requirement is not met as evidenced by: Based on LPA's interviews with Staff #1 and Staff #2 it was determined that infant had worken up and was not removed from the crib soon after.
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Per Director, staff was given a training on Safe Sleep and told to make sure that crib latch is secure. Director also informed staff during the visit that if an infant wakes up from their nap they should be taken out of the crib immediately.
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Child #1 stood up and due to the crib door not being properly latched caused Child #1 to fall out the crib.This poses a potential 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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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