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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198009833
Report Date: 08/24/2026
Date Signed: 08/24/2026 10:48:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2026 and conducted by Evaluator Veronica Martinez-Garza
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20260602113547
FACILITY NAME:ANNEX MONTESSORI CHILDCARE CENTERFACILITY NUMBER:
198009833
ADMINISTRATOR:HAYDEE DIAZFACILITY TYPE:
850
ADDRESS:3400 AEROJETTELEPHONE:
(626) 569-2641
CITY:EL MONTESTATE: CAZIP CODE:
91731
CAPACITY:37CENSUS: 10DATE:
08/24/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dima DeranivagalaTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not provide adequate supervision to a daycare child
INVESTIGATION FINDINGS:
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On 08/24/26 at 9:15 a.m., Licensing Program Analyst (LPA) Veronica Martinez Garza conducted an unannounced complaint investigation to deliver findings to the above allegation. At 9:23 a.m., LPA met with the facility representative Dimanthi “Dima” Deranivagala who guided LPA on a tour of the facility. There were 10 children with 3 staff.

According to the Reporting Party (RP), “Staff did not provide adequate supervision to a daycare child.” LPA conducted interviews with staff 1 (S1) thru 5, child 2 (C2) thru 5, and parent 1 (P1) thru 5. LPA also obtained a copy of the facility roster, copy of the parent handbook and documents pertaining to C1.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026
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 8
Control Number 33-CC-20260602113547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ANNEX MONTESSORI CHILDCARE CENTER
FACILITY NUMBER: 198009833
VISIT DATE: 08/24/2026
NARRATIVE
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Allegation- Staff did not provide adequate supervision to a daycare child. According to the RP, on 05/15/26 C1 sustained a severe bump to the forehead and staff stated that the child was trying to get away from another child when the child fell and their head on a wooden chair. The RP stated that the facility has cameras; however, the facility did not allow the RP to view the footage, stating that the cameras are “dummy cameras.” LPA conducted an interview with RP who revealed that on 05/15/26 the facility contacted them regarding the incident and assessed C1 injury. According to the RP, S1 stated they witnessed the incident but then stated they were not present when the incident occurred. RP also stated that an ouch report was not provided and was informed by S1 that the ouch report would be fixed. Per RP, they received conflicting statements and video footage was requested to determine how C1 sustained their injury.

LPA conducted interviews with S1 thru 3. Interview with S1 revealed that they were sitting next to C1 while doing an art activity at the wooden table. According to S1, C1 got up from the chair and their foot got caught on the chair’s leg which caused the child to fall and hit their head on the corner of the wooden chair. LPA took pictures of the wooden table and chair which were observed age-appropriate and in good condition. S1 also revealed that when C1 sustained the injury, it wasn’t because the child was trying to get out of the chair or being chased by another child. S1 denied stating that the child was running away from another child and reiterated that C1 was doing an art project when the incident occurred.

Interview with S2 revealed that C1 tripped, fell, and hurt themselves on a wooden chair; first aid was provided. According to S2, S1 was present when the incident occurred and parents were notified.

Interview with S3 revealed that C1 was walking when the child tripped with the legs of the chair as the child was trying to go around and hit their head on the table.

LPA attempted to conduct interviews with C2 thru 5; however, due to their young age, a statement couldn’t be obtained. LPA conducted interviews with P1 thru 5. Parent interviews did not reveal evidence to support the allegation.

LPA received a copy of the ouch report dated 05/15/26. The report states that at 9:25 a.m., during snack time, C1 was running from a classmate when the child tripped. The ouch report then continues with an added statement “during art time,”. LPA observed that S1 completed the ouch report; however, the staff’s interview contradicts what is documented on the ouch report. There is an email response regarding C1 on 05/18/26. All staff interviewed revealed that C1 fell and hit their head; however, there are discrepancies on how it happened and who witnessed the incident. The reason for the conflicting statements is unknown.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 33-CC-20260602113547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ANNEX MONTESSORI CHILDCARE CENTER
FACILITY NUMBER: 198009833
VISIT DATE: 08/24/2026
NARRATIVE
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This agency has investigated the complaint alleging “Staff did not provide adequate supervision to a daycare child.” Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, the following deficiencies are being cited (see attached 9099D).

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and a copy of this report was provided to facility representative Dima Deranivagala.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 33-CC-20260602113547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ANNEX MONTESSORI CHILDCARE CENTER
FACILITY NUMBER: 198009833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2026
Section Cited
CCR
101229(a)
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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.

This requirement is not met as evidenced by:
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Per facility representative, facility will ensure that there are two staff present when children are at the table for any activity. Smaller groups for activities has been set in place to ensure all children are supervised. A staff meeting was held and a meeting agenda will be submitted to LPA.
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All staff interviewed revealed that C1 fell and hit their head; however, there are discrepancies on how it happened and who witnessed the incident. The reason for the conflicting statements is unknown which poses a potential health, safety or personal rights risk 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: Ana Chico
LICENSING EVALUATOR NAME: Veronica Martinez-Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8