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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444408893
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:41:11 PM

Document Has Been Signed on 11/08/2021 01:41 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:QUAIL HOLLOW MONTESSORIFACILITY NUMBER:
444408893
ADMINISTRATOR:CYNTHIA LAURINFACILITY TYPE:
850
ADDRESS:187 LAUREL DRIVETELEPHONE:
(831) 335-4710
CITY:FELTONSTATE: CAZIP CODE:
95018
CAPACITY: 42TOTAL ENROLLED CHILDREN: 42CENSUS: 32DATE:
11/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Martina ErsunayTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Goodell met with Assistant Director Martina Ersunay for a Case Management inspection. LPA obtained a census of 9 children with one staff member in the outdoor area and 23 children with 4 staff members in the preschool classroom. During the investigation, LPA toured classrooms, restrooms and outdoor area. LPA observed during file review that staff #1 was lived scanned however has not obtained a fingerprint clearance through Community Care Licensing and is present at the facility which poses an immediate to risk to children in care. LPA spoke to Melinda Gillan via phone call who acknowledged requirement and stated proof of emails to Guardian regarding staff #1 livescan clearance will be submitted to LPA by POC due date. During inspection LPA also observed the facility's thermostat temperature at 64 degrees which is less than the required minimum temperature of 68 degrees which poses a potential risk to children in care. Staff acknowledge requirement and stated thermostat was reset and proof will be submitted to LPA by POC due date.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files. Report reviewed and discussed. Notice of Site Visit issued and must remain posted for 30 days. Appeal Rights also issued and discussed.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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 11/08/2021 01:41 PM - It Cannot Be Edited


Created By: Kristal Goodell On 11/08/2021 at 01:07 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: QUAIL HOLLOW MONTESSORI
FACILITY NUMBER: 444408893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met due to LPA observed during file
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LPA spoke to Melinda Gillan via phone call who acknowledged requirement and stated proof of emails to Guardian regarding staff #1 livescan clearance will be submitted to LPA by POC due date 11/9/2021.
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review that staff #1 was lived scanned however has not obtained a fingerprint clearance through Community Care Licensing and is present at the facility which poses an immediate to risk to children in care. CIVIL PENALTY ASSESSED
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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:Diana Stephenson
LICENSING EVALUATOR NAME:Kristal Goodell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2021 01:41 PM - It Cannot Be Edited


Created By: Kristal Goodell On 11/08/2021 at 01:22 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: QUAIL HOLLOW MONTESSORI
FACILITY NUMBER: 444408893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited
CCR
101239(a)(1)

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Fixtures, Furniture, Equipment and Supplies. The licensee shall maintain the temperature in rooms that children occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). This requirement is not met due to LPA observed the facility's thermostat temperature at 64 degrees
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Staff acknowledge requirement and stated thermostat was reset and proof will be submitted to LPA by POC due date 11/9/21.
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which is less than the required minimum temperature of 68 degrees which poses a potential risk to 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:Diana Stephenson
LICENSING EVALUATOR NAME:Kristal Goodell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


LIC809 (FAS) - (06/04)
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