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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616551
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:28:45 PM

Document Has Been Signed on 06/08/2022 04:28 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:COUNTRYHILL MONTESSORIFACILITY NUMBER:
343616551
ADMINISTRATOR:WALKER, REONNAFACILITY TYPE:
850
ADDRESS:7048 SUNRISE BLVD.TELEPHONE:
(916) 728-2929
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 102TOTAL ENROLLED CHILDREN: 102CENSUS: 53DATE:
06/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Anna RoyalTIME COMPLETED:
04:45 PM
NARRATIVE
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At 9:45 a.m. Licensing Program Analyst (LPA) Karyn Guerra met with Director, Anna Royal, for the purpose of a case management inspection. A COVID-19 risk assessment was conducted. LPA came to learn of unusual incidents that occurred on 6/2/2022. The department was not notified of the incidents by the next business day. This poses a potential risk to the health and safety of children in care. LPA also conducted technical assistance regarding COVID-19 reporting requirements.

A title 22 deficiency is cited on the subsequent page of this report. An exit interview was conducted and appeal rights were provided. Director's signature on this report acknowledges receipt of these rights. A notice of site visit was provided and shall remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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 06/08/2022 04:28 PM - It Cannot Be Edited


Created By: Karyn Guerra On 06/08/2022 at 01:08 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COUNTRYHILL MONTESSORI
FACILITY NUMBER: 343616551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
101212(d)

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101212 Reporting Requirements(d) Upon the occurrence...of any of the events specified...a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified...shall be submitted to the Department within seven days following the occurrence of such event...This requirement was not met, as evidenced by:
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Facility will provide an unusual incident report form LIC624 to the department by the POC due date.
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Based on file review, the facility did not report unusual events that occurred on 6/2/2022 to the department.
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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:Seychelle De Luca
LICENSING EVALUATOR NAME:Karyn Guerra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022


LIC809 (FAS) - (06/04)
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