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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283008069
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:42:34 AM

Document Has Been Signed on 10/04/2023 11:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NAPA VALLEY MONTESSORI LEARNING CENTER - P/SFACILITY NUMBER:
283008069
ADMINISTRATOR:SMITH, TERESITAFACILITY TYPE:
850
ADDRESS:120W AMERICAN CANYON ROAD M 11TELEPHONE:
(707) 853-9580
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 37TOTAL ENROLLED CHILDREN: 37CENSUS: 22DATE:
10/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Todd PetersonTIME COMPLETED:
11:45 AM
NARRATIVE
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On October 4, 2023 at 9:15 am Licensing Program Analysts (LPAs) Mindy Mohr and Cindy Castro conducted an unannounced case management visit due to subsequent information received. LPAs conducted further interviews and determined D2 was previously uncleared to be in the facility alone while supervising children from 07/05/2022 through 06/06/2023. D2 has since obtained a clearance . It was further revealed that an unqualified staff member (S2) was providing care and supervision to children.

Title 22 deficiency is being cited on the attached LIC 809D and a $500 civil penalty is being issued. Appeal Rights were provided.



LPAs Mohr and Castro informed D2 that this report dated 10/04/23 documents one Type A citation which shall be posted for 30 consecutive days as there is was immediate risk to the health, safety, or personal rights of children in care. LPAs Mohr and Castro informed D2 to provide a copy of this licensing report dated 10/04/23 that documents any Type A citation(s) 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 statement, must be placed in the child's file for verification.

Exit interview conducted, and report was reviewed with facility representative Todd Peterson.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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Document Has Been Signed on 10/04/2023 11:42 AM - It Cannot Be Edited


Created By: Melinda Mohr On 10/04/2023 at 09:57 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAPA VALLEY MONTESSORI LEARNING CENTER - P/S
FACILITY NUMBER: 283008069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/04/2023
Section Cited
CCR
101170(e)(1)

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101170(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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D2 obatained a criminal record clearance on 06/06/23 and is cleared.
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This requirement is not met as evidenced by:
Based on interviews conducted D2 was previously uncleared to be in the facility alone while supervising children from 07/05/2022 through 06/06/2023. .
This poses a immediate health and safety risk to children in care.
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CCR

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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:Leslie Lepori
LICENSING EVALUATOR NAME:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2023 11:42 AM - It Cannot Be Edited


Created By: Melinda Mohr On 10/04/2023 at 10:54 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAPA VALLEY MONTESSORI LEARNING CENTER - P/S
FACILITY NUMBER: 283008069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
101216.1(j)

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101216.1 (j) Each teacher shall visually observe aides under his/her supervision whenever the aide is working with children, except as provided for in Sections 101216.2(e)(1) and 101230(c)(1).

This requirement is not met as evidenced by:
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Director stated S2 is currently enrolled in courses to complete 12 units of ECE. D2 stated they will develop a staffing plan to be in compliance with regulation and will email LPA Mohr @ melinda.mohr@dss.ca.gov within 10 days.
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 Based on interviews conducted it was corrobored that an aide (S2) was left alone and was providing care and supervision to children.
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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