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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216043
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:50:39 PM

Document Has Been Signed on 10/01/2024 12:50 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SIMI VALLEY MONTESSORI SCHOOL - WEST VALLEYFACILITY NUMBER:
566216043
ADMINISTRATOR/
DIRECTOR:
ROSHINI WIREKOONFACILITY TYPE:
850
ADDRESS:15 MCCOY PLACETELEPHONE:
(818) 667-5205
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: DATE:
10/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On October 1, 2024 at 01:32 PM, Licensing Program Analyst (LPA) Aaliyah Zendejas made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPA met with Director Roshini Wirekoon to discuss an incident that was self reported to Community Care Licensing Division (CCLD) office via email on 09/19/2024. LPA toured the classroom area where the incident occurred and took note of what staff members were present and what the ratio was for the day of the incident.

On September 18, 2024 an incident occurred at the center around 1:45 PM. While C1 was running within the classroom, C1 ended up tripping and while falling, hitting their head on a wooden shelf. C1 received a cut on the side of their head. S1 and S2 then cleaned the wound that had formed on the child's head and placed an ice pack on their head. Staff called the parents of the child immediately after the incident to report, and parent came to pick up the child.

The child returned to the facility. To prevent any similar incidents, the licensee has been instructed to remain keeping children in constant supervision, and to encourage children to be mindful of the objects around them as well as for the staff to be mindful of any potentially harmful objects.

Given the incident was observed by staff who took appropriate action by immediately reporting to licensing and the parent of the child as well as implementing changes to ensure children are constantly observed and harmful objects taken out of the facility if applicable, no deficiencies are being cited as a result of this incident.

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.
Appeal Rights were provided to Director Roshini Wirekoon.
Exit interview conducted and report was reviewed with the Director Roshini Wirekoon
SUPERVISORS NAME: Lissete Gonzalez
LICENSING EVALUATOR NAME: Aaliyah Zendejas
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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