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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364830892
Report Date: 08/25/2021
Date Signed: 08/25/2021 03:36:00 PM

Document Has Been Signed on 08/25/2021 03:36 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:MONTESSORI ACADEMY OF CHINOFACILITY NUMBER:
364830892
ADMINISTRATOR:DE SILVA, MAVANANEFACILITY TYPE:
850
ADDRESS:4511 RIVERSIDE DRIVETELEPHONE:
(909) 591-3937
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 23DATE:
08/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Ariana Gomez Assistant Director TIME COMPLETED:
03:45 PM
NARRATIVE
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A case management was conducted by LPA Rachel Zeron in regards to complaint # 09-CC-20210813095403 and 09-CC-20210728162251, LPA met with Ariana Gomez and toured the facility. During the course of the investigation it was found that the Private elementary and the preschool program were commingling on the playground from the hours of 7:00 am to 8:00 am. LPA observed the schedules for both teachers and children and found that there was one teacher supervising both Kindergarten and Preschool children on the playground.

Upon receipt of this report, licensee is required to provide a copy of the LIC809D documenting Type A deficiencies to children's parents and obtain signatures from the parents on Form LIC9224. For the next 12 months, licensee is required to provide a copy of the LIC9099D to all newly enrolled families. A copy of this report must be made available to the public upon request for the next 3 years.

An exit interview was conducted. A copy of this report was provided .A Notice of site visit was given to the Director and LPA observed the notice posted. Director agreed to keep the notice posted for the next 30 days.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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 08/25/2021 03:36 PM - It Cannot Be Edited


Created By: Rachel Zeron On 08/25/2021 at 03:21 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MONTESSORI ACADEMY OF CHINO
FACILITY NUMBER: 364830892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2021
Section Cited
CCR
101161(a)

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 Limitations on Capacity and Ambulatory Status. The licensee shall not exceed the conditions, limitations and capacity specified in the license. This requirement was not met as evidenced by: LPA observed school age children commingle with the pre school program children. Two school age program children were allowed to move freely between both programs.
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Assistant administrator is coming in at 7:00 am to supervise the kindergarten children.

Schedule was reviewed. POC cleared
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This conduct poses a potential risk to the health and safety of 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:Kimberly Williams
LICENSING EVALUATOR NAME:Rachel Zeron
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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