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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304270588
Report Date: 06/26/2019
Date Signed: 06/27/2019 03:53:06 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2019 and conducted by Evaluator Stacy Torrence
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20190528111621
FACILITY NAME:IVYCREST MONTESSORI PRIVATE SCHOOLFACILITY NUMBER:
304270588
ADMINISTRATOR:TAKEDA, CLAIREFACILITY TYPE:
830
ADDRESS:2025 E. CHAPMAN AVENUETELEPHONE:
(714) 879-6091
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:32CENSUS: 24DATE:
06/26/2019
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Aida King, DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is operating out of ratio
Facility staff failed to meet day care children's diapering needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Torrence conducted an unannounced visit to the above facility on 06/26/2019 at 9:05 a.m. to follow up on the complaint investigation that was conducted on 06/03/2019. LPA met with Director Aida King, who guided analyst on a tour of the facility. Census was taken. There was a total of 24 children and nine staff supervising. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Allegation: Facility is operating out of ratio. It was reported that there are many days and times where one teacher is watching 6-8 infants, and sometimes more, without another teacher. During today’s inspection, LPA Torrence interviewed four staff and obtained a copy of the diaper changing sheet and staff schedule ratio. During interviews conducted by LPA Torrence on 06/03/2019 and 06/26/2019, Staff 1 disclosed that she has witness the classroom being out of ratio on several occasion.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
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 5
Control Number 06-CC-20190528111621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IVYCREST MONTESSORI PRIVATE SCHOOL
FACILITY NUMBER: 304270588
VISIT DATE: 06/26/2019
NARRATIVE
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Page 2 9099C

Staff 1 reported the following: On 06/24/2019 at 8:10 a.m., she had 5 infants, at 8:25 a.m. she had 5 infants, at 8:26 a.m. she had 6 infants, at 8:43 a.m. she had 6 infants and on 06/26 today, at 8:17 a.m. she had 6 infants, between 8:19 a.m. and 8:25 a.m. she had 6 infants; at 8:55 a.m. she had 7 infants, at 8:56 a.m. herself and another staff had 9 infants, and at 9:00 a.m. she had 10 infants. Staff 1 reported that she has heard prospective parents ask if the ratio is 1:4 why does that teacher have so many kids. Staff 2 reported that she has witness the classroom being out of ratio sometimes. Staff 2 stated that out of ratio frequently occurs around 11:00 a.m. to 11:30 a.m. Staff 2 reported that she has noticed that one staff with 10 infants at at one time. Staff 2 disclosed that while she was conducting an activity with another staff they had 11 infants. Staff 4 disclosed that she has witness the classroom being out of ratio sometimes because staff is either late, leave early or call in sick. Staff 4 stated that the ratio is 1 staff and 6 infants or one staff and 7 infants. Staff 4 reported that most time the director send staff but sometimes there’s not enough staff. Staff 5, 6, 9, and 10 disclosed that the facility is in ratio. Staff 7 reported that the staff wait until they send a teacher to help them and that they are not out of ratio because help is sent. Staff 8 stated that when they see they’re going to be out of ratio they call the front desk for help. According to the staff schedule ratio form, the classroom has enough staff to cover ratio at all times and also showing extra staff to help out; however, it was reported by staff that even though there's enough staff in the classroom to cover ratio, some of the staff is doing other activities, not visually supervising the children and leaving the other staff out of ratio.

Allegation: Facility staff failed to meet day care children’s diapering needs. It was reported that it is suspected that children are not getting changed as much as they should, or as much as parents are told. During today’s inspection, LPA Torrence interviewed four staff and obtained a copy of the diaper changing sheet. During interviews conducted by LPA Torrence on 06/03/2019 and 06/26/2019 Staff 1 disclosed that there weren’t enough staff changing diapers. Staff 1 reported that she was told to only worry about the poopy diapers; however, she stated that she tried to change all the diapers. Staff 1 reported that she was told that they didn’t have enough staff to change all the children. Staff 1 also stated that she was told to change the younger children under the age of 1 year old once every hour and the older children every 2 hours. Staff 1 don’t believe that was being done because she was told they do not have enough staff. Staff 1 disclosed that the first change is at 11:30 a.m. and the next change is at 2:30 p.m. Staff 1 reported that she was told not to change the children if they were laying in their beds, drinking or sleep; however, she stated that there were days when she would go ahead and check those children and they were wet. Staff 1 reported that the children are not being changed as needed.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 06-CC-20190528111621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: IVYCREST MONTESSORI PRIVATE SCHOOL
FACILITY NUMBER: 304270588
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/27/2019
Section Cited
CCR
101428(b)(2)
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101428(b)(2) Infant Care Personal Services.The infant shall be kept clean and dry at all times. Each infant's clothing and diapers shall be changed as often as necessary to ensure that the infant is clean and dry at all times. The requirement is not met as evidenced by Staff 1 disclosed that there weren’t enough staff to change all the
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Per Director, they have a rotating schedule for staff to change diapers. Director provided LPA with a copy of that schedule.
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diapers. Staff 1 stated that she was told to only worry about the poopy diapers. Staff 1 also stated that she was told to change the younger children under the age of 1 year old once every hour and the older children every 2 hours. Staff 1 reported that the children are not being changed as needed. Staff 2 disclosed that between 11:00 a.m. to 12:00 p.m. would only check for bowl movements, did not automatically change all the children.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 06-CC-20190528111621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IVYCREST MONTESSORI PRIVATE SCHOOL
FACILITY NUMBER: 304270588
VISIT DATE: 06/26/2019
NARRATIVE
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Page 3 9099C

Staff 1 stated that another staff told her if the diaper is full change the child; however, if it’s a little wet don’t change the child. Staff 2 disclosed that between 11:00 a.m. to 12:00 p.m. would only check for bowl movements, did not automatically change all the children. Staff 3 reported that she would change every hour or as needed. Staff 4 stated that she changes the diapers at the end of the day, when they come back from outside between 5:00 p.m. to 6:00 p.m., to make sure the diapers are changed before the children go home. Staff 5 reported that a record for each infant diaper changing is completed. Staff 5, 6, 7, and 8 stated that the schedule to change the children are every 2 hours; however, if there’s a need to change we don’t wait. Staff 5, 6, and 8 stated that they keep a diaper changing log. Staff 5, 6, and 7, reported that parents sometimes give diaper cream for their child and we have them sign an authorize form and they follow the instruction of the parents. After review of the staff diaper changing sheet, it was discovered that the children are changed every 2 hours, there’s no indication that the children are changed any other times during the day.

Based on LPAs interviews conducted with 10 staff members and review of the diaper changing sheet the preponderance of evidence standard has been met; therefore the 101416.5(a)(b) Out of Ratio and 101428(b)(2) Infant Care Personal Services allegations are found to be substantiated. California Code of Regulations, Title 22, Division 12 & Chapter 1, is being cited on the attached LIC 9099D.



If the facility receives a Type A violation, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days.

Exit interview was conducted. The report was reviewed and discussed. The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 06-CC-20190528111621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: IVYCREST MONTESSORI PRIVATE SCHOOL
FACILITY NUMBER: 304270588
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/27/2019
Section Cited
CCR
101416.5
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101416.5(a)(b) Staff-Infant Ratio.
In addition to Sections 101216.3 (c), (e), (g) and (h), and notwithstanding Sections 101216.3, (a), (b), (d) and (f), the following shall apply: There shall be a ratio of one teacher for every four infants in attendance. The requirement is not met as evidence by Staff 1 reported that on 06/24/19 and 06/26/19, the infant classroom was out of ratio at various times of the day.
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Per Director, she has extra staff in the classroom as needed to do other activities in the classroom while still maintaining ratio. Director provided LPA with a copy of the staff schedule ratio form.
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Staff 2 disclosed the classroom is out of ratio frequently around 11:00 a.m. to 11:30 a.m. Staff 2 reported that she has noticed one staff with 10 infants at a time. Staff 4 disclosed that she has witness the classroom being out of ratio sometimes. This poses an immediate risk to the safety of 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC9099 (FAS) - (06/04)
Page: 5 of 5