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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434404307
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:13:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2021 and conducted by Evaluator James G Santos
COMPLAINT CONTROL NUMBER: 07-CC-20210629091517
FACILITY NAME:CASA DI MIR MONTESSORI ELEMENTARY SCHOOLFACILITY NUMBER:
434404307
ADMINISTRATOR:SUNITA AUSTINFACILITY TYPE:
850
ADDRESS:90 EAST LATIMER AVENUETELEPHONE:
(408) 370-3073
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:60CENSUS: 32DATE:
09/27/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Wanda Whitehead, Director of EducationTIME COMPLETED:
11:23 AM
ALLEGATION(S):
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Child was left unsupervised by staff for an extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), James Santos conducted an unannounced subsequent complaint visit today and met with Wanda Whitehead, Director of Education. The purpose of today's visit was to deliver the investigation finding for the above allegation.

During the course of investigation, LPA conducted interviews with staff. Based on the interviews regarding the incident, it has been determined that the child (C1) went inside a different classroom without staff visual observation. The child was later found when staff walked inside the classroom.

Based on the information gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

See LIC9099D page for deficiency cited. Exit interview conducted and copy of this report and appeal rights form provided to the facility.

NOTICE OF SITE VISIT WAS ISSUED TO FACILITY AND WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 07-CC-20210629091517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CASA DI MIR MONTESSORI ELEMENTARY SCHOOL
FACILITY NUMBER: 434404307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2021
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision.
(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director agreed to write an updated supervision plan and discuss with staff to ensure that all children will be visually supervised and accounted for at all times, including transition. POC to be submmited to LPA by due date, 9/28/2021 .
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This requirement was not met as evidenced by: Based on the interviews with staff, the child (C1) went inside a different classroom without staff visual observation leaving the child unsupervised. This poses an immediate threat to health and safety of children in care.
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*Civil penalty assessed - Immediate $500 Violation.

According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file. LPA advised Director that an Office Meeting will be scheduled at a later date. Written notification of the office meeting will be sent to Licensee via mail.
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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.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2