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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413036
Report Date: 05/26/2023
Date Signed: 05/26/2023 01:33:03 PM

Document Has Been Signed on 05/26/2023 01:33 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GLOBAL VILLAGE MONTESSORIFACILITY NUMBER:
434413036
ADMINISTRATOR:SELVASUMATHI NAMOKAREANFACILITY TYPE:
850
ADDRESS:1146 JACKLIN ROADTELEPHONE:
(408) 956-8711
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 36DATE:
05/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director Sushma Shrestha and Licensee Nikki YelamTIME COMPLETED:
02:00 PM
NARRATIVE
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On Friday, May 26, 2023, at 9 am, Licensing Program Analyst (LPA) conducted a Case Management - Incident Visit. LPA met with the Director Sushma Shrestha and Licensee Nikki Yelam and explained the nature of the visit. Present on this visit were Staff 8 and 36 Children. The facility operates from Monday to Friday 8am to 5:30 pm.

On Wednesday, May 24, 2023, at 4 pm, the Director reported an Unusual Incident to the Oakland Southeast Regional Child Care Office via phone. The Unusual Incident was about C1 was found by P1 outside at the sidewalk of the side parking lot adjacent from the outdoor play exit door without supervision of a teacher on Tuesday, May 23, 2023, at 4:26 pm. P1 brought in C1 through the front door and reported the incident to the Director.

LPA conducted staff interview, a health and safety inspection, record review and obtained copies of the facility's sign in and out sheets and correspondence.

Based on LPA Estoesta Staff Interview, that C1 was playing at the outdoor play area and exited the outdoor play area exit door without a supervision S1. In addition, the outdoor play area exits door's alarm system was malfunctioning and did not alarm when C1 opened and exited the door. The facility is in violation of Section 101229 (a)(1) that no child(ren) shall be left without the supervision, including visual supervision, of a teacher at any time, except as specified in sections 101216.2 (e)(1) and 101230 (c)(1).

See 809 C.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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 05/26/2023 01:33 PM - It Cannot Be Edited


Created By: Manel Estoesta On 05/26/2023 at 09:12 AM
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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GLOBAL VILLAGE MONTESSORI
FACILITY NUMBER: 434413036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
101229(a)(1)

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No child(ren) shall be left without the supervision,
including visual supervision, of a teacher at any time, except as
specified in sections 101216.2 (e)(1) and 101230 (c)(1).......
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Director will conduct and document a Staff Meeting focusing on Supervising Children in Child Care Centers, Licensee will provide a work order on the outdoor play area malfunctioned exit door, Licensee and the Director will present a written plan on how to prevent this incident.....
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On 05/23/2023 at approximately 4:26 PM, C1 was found by P1 outside at the sidewalk of the side parking lot adjacent from the outdoor play exit door without supervision of a teacher, which was an immediate risk to the health, safety, or personal rights of C1.
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in the future and will submit a copy to Oakland Southeast Regional also. A plan also will be shared to all the Children's Authorized Representative on or by the 6/30/23. LPA Estoesta suggested that all of the Staff to watch and review the Supervision Video on https://ccld.childcarevideos.org.

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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:Jason Jang
LICENSING EVALUATOR NAME:Manel Estoesta
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GLOBAL VILLAGE MONTESSORI
FACILITY NUMBER: 434413036
VISIT DATE: 05/26/2023
NARRATIVE
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Continuation.

LPA Estoesta informed the Director and that this report dated 05/26/2023 included a Type A Citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Estoesta informed the Director to provide a copy of this licensing report dated 05/26/2023 that document of any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Licensee Nikki Yelam.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
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