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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213004840
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:17:56 PM

Document Has Been Signed on 04/21/2022 02:17 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ABBEY MONTESSORI CHILDREN'S CENTER - PRESCHOOLFACILITY NUMBER:
213004840
ADMINISTRATOR:COSTELO, ELIZABETHFACILITY TYPE:
850
ADDRESS:138 N. SAN PEDRO ROADTELEPHONE:
(415) 479-8865
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 25DATE:
04/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lourdes AncaTIME COMPLETED:
02:25 PM
NARRATIVE
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On 4/21/2022 at 9:10A.M. Licensing Program Analyst (LPA) Luis J. Gomez conducted an unannounced complaint investigation today and met with Lead Teacher, Lourdes Anca. Purpose of report is case management to cite for deficiencies observed during complaint inspection. LPA inspected facility, indoors and outdoors, with Lead Teacher for health and safety hazards.

During today’s inspection, LPA reviewed facility records, interviewed staff and performed observations.

At 9:20A.M. Based on observation, interviews and file review, LPA confirmed facility has installed dividing wall in the outdoor play area, without prior department notification. Per lead teacher, fencing was placed during pandemic.

At 11:50A.M., Based on observations, LPA confirmed canopy in outdoor play area not properly anchored.

Based on today’s inspection, deficiencies were observed in the areas evacuated according the Title 22 Division 12 of Ca. Code of Regulations and cited on the 809D. An exit interview was conducted with lead teacher, and plan of correction was discussed. A copy of this report with the appeal rights was provided, and signature of this form acknowledges the receipt of these documents.

A copy of this report was reviewed and left with the lead teacher. Notice of site visit was provided and shall remain posted for 30 days.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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Document Has Been Signed on 04/21/2022 02:17 PM - It Cannot Be Edited


Created By: Luis Gomez On 04/21/2022 at 01:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ABBEY MONTESSORI CHILDREN'S CENTER - PRESCHOOL
FACILITY NUMBER: 213004840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
101212(c)

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101212(c) Reporting Requirement: The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions. This requirement was not met as evidenced by:
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Lead Teacher will submit an updated facility sketch (LIC999) to CCL with written plan on how space will be made accessible to day-care children at all times by the due date: 4/29/2022.
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Based on observation, interviews and file review, LPA confirmed facility has installed dividing wall in the outdoor play area, without prior department notification. This poses a potential health or safety risk to children in care.
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Proof of correction will be submitted to the department via email.
Type B
04/25/2022
Section Cited
CCR101238.2(d)(2)

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101238.2(d)(2) Outdoor Activity Space:Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard. This requirement was not met as evidenced by:
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Lead teacher will ensure canopy is properly anchored/ and or replaced by the due date: 4/25/2022
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Based on observations, LPA confirmed canopy in outdoor play area not properly anchored. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to the department via email.
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:Cindy Interiano
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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