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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401710931
Report Date: 08/08/2022
Date Signed: 08/08/2022 02:31:59 PM

Document Has Been Signed on 08/08/2022 02:31 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:ARROYO GRANDE MONTESSORI SCHOOLFACILITY NUMBER:
401710931
ADMINISTRATOR:MICHAEL MILLERFACILITY TYPE:
850
ADDRESS:216 OAK STREETTELEPHONE:
(805) 473-2979
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 6DATE:
08/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Elizabeth SilvaTIME COMPLETED:
02:45 PM
NARRATIVE
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On 8/8/22, at 1:45 PM, Licensing Program Analyst (LPA) Elvin Baddley made an unannounced Case Management inspection at the abovementioned Child Care Center (CCC). LPA met with Elizabeth Silva, Assistant Director of CCC and explained the nature of the inspection. LPA note six children are present along with 1 assistant providing care and supervision.

The Case Management inspection follows a One Year Required Inspection which took place on 8/5/22, at which time LPA learned the Licensee the CCC, DEJ INC., was terminated. It should be noted prior the 8/5/22, CCLD was not informed of the termination of the LIcensee or a change of ownership. LPA informed Assistant Director organizational changes needed to be reported to CCLD within 10 working days following their occurrence pursuant to regulations (CCR 101212 (a)(e)(1)).

A Type B Deficiency are being cited based on LPA’s observations/ record review pursuant to Title 22 of the CA Code of Regulations (refer to LIC 809-D).

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Assistant Director A copy of this report was provided to the Assistant Director, whose signature is on this form confirms receipt of this document.

Assistant Director was provided a copy of their appeal rights (LIC 9058). The LIC 9213 (Notice of Site visit) was provided and must remain posted for 30 days..

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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 08/08/2022 02:31 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Elvin Baddley On 08/08/2022 at 01:56 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: ARROYO GRANDE MONTESSORI SCHOOL
FACILITY NUMBER: 401710931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
08/17/2022
Section Cited
CCR
101212(a)(e)(1)

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Reporting Requirements- (a) Each licensee or applicant shall furnish to the Department reports as required by the Department including, but not limited to, the following: (e) The items below shall be reported to the Department within 10 working days following their occurrence: (1) Organizational changes
Sections 101185(a)(2) through (a)(5).
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Assistant Director directed to submit documentions for a CCC outlined in LIC 281 (a)
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This requirement was not met as evidenced by CCLD not being informed of the terminastion or change of DEJ INC. as the facility's Licensee within 10 business days.
This poses a potential health, safety or personal rights risks to persons 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:Maria Mueller
LICENSING EVALUATOR NAME:Elvin Baddley
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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