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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624324
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:09:46 PM

Document Has Been Signed on 10/02/2024 12:09 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADVENTURE MONTESSORI S.T.E.A.M ACADEMY LLCFACILITY NUMBER:
343624324
ADMINISTRATOR/
DIRECTOR:
ROBERTA MANLEYFACILITY TYPE:
850
ADDRESS:3541 N FREEWAY BLVD SUITE 100TELEPHONE:
(916) 370-6113
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 22DATE:
10/02/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Sithumini MillawabandaraTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Mandie Goodwin and Kyrsten Williams met with Licensee, Sithumini Millawabandara, for the purpose of an unannounced plan of correction inspection. Census included 22 preschool children supervised by three staff member.

On September 17th, 2024, licensee was issued three type B citations. Facility was cited for children files missing preadmission health history- parent's reports and physician reports. Facility was also cited for children files missing the LIC9224, which informs families that a type A citation was given and acknowledges that representatives received a copy of the report documenting the type A citation. Lastly, facility was cited due to staff files missing immunization records for Measles, Pertussis, and Influenza. To correct the deficiency LPAs returned to review files. LPAs observed health screenings in a sample of files. LPA additionally observed immunization records for staff members present. Deficiency was cleared and a letter was provided for these two citations.

LPAs did not observe the LIC9224- Acknowledgement of receipt of licensing reports. The LIC9224 must be signed the same day a Type A citation is given or the next time a child is in care. Licensee stated that they provided the paper to families and gave them a time frame to bring it back, which was after the Plan of Correction date.

A civil penalty of $100 was assessed due to a failure to correct the deficiency by the Plan of Correction date. The civil penalty will continue to accrue $100 per day until the deficiency is corrected.

Report was reviewed with Licensee Sithumini Millawabandara and exit interview was conducted. A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
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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