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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020471
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:37:36 PM

Document Has Been Signed on 10/14/2022 03:37 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:ACACIA MONTESSORI SCHOOL COVINA INC.FACILITY NUMBER:
198020471
ADMINISTRATOR:MILDRED BAUTISTAFACILITY TYPE:
850
ADDRESS:450 W ROWLAND STTELEPHONE:
(626) 966-9356
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 60TOTAL ENROLLED CHILDREN: 52CENSUS: 20DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mildred BautistaTIME COMPLETED:
03:45 PM
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On 10/14/2022 LPA, Carolyn Tuba had Director, Mildred Bautista sign a copy of amended LIC 9099 dated 10/12/2022. A COVID-19 risk assessment was conducted prior to entering. LPA took a census of 20 children present with 3 staff.

An exit interview was conducted, and a copy of this report was provided, along with Notice of Site Visit and Appeal Rights to the Director, Mildred Bautista.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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