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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370185
Report Date: 05/08/2019
Date Signed: 06/28/2019 12:16:58 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
05/02/2019 and conducted by Evaluator Sherene Hawkins
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20190502095100
FACILITY NAME:INT'L CHRISTIAN MONTESSORI ACADEMY OF NEWPORTFACILITY NUMBER:
304370185
ADMINISTRATOR:RIVERO, MYRIAM S.FACILITY TYPE:
850
ADDRESS:2591 IRVINE AVENUETELEPHONE:
(949) 631-9749
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:76CENSUS: 55DATE:
05/08/2019
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Myriam RiveroTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility failed to keep staff files including immunization records, mandated reporter certificates, and transcripts
INVESTIGATION FINDINGS:
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The purpose of this inspection was to conduct a Complaint Investigation of the facility in regards to facility failing to keep complete files of staff. Census was taken in individual classrooms. The overall census observed was 8 preschool staff, 48 preschool children, and 2 toddler option staff and 7 toddler children.
A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
During today's inspection LPA Hawkins reviewed 10 staff files, interviewed 4 staff and toured facility.
During investigation and file review it was discovered that S2 file was missing mandated reporter training and influenza; S3 and S9 file was missing influenza records; S4 and S7 file was missing required vacination of measles and influenza; S5 file was missing health screening, vacination of measles, pertusis and influenza.

Based on file review and interviews conducted, the facility failed to maintain complete staff files which should include immunization records, mandated reporter certificates, and trascripts. continued on page 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2019
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 4
Control Number 06-CC-20190502095100
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: INT'L CHRISTIAN MONTESSORI ACADEMY OF NEWPORT
FACILITY NUMBER: 304370185
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2019
Section Cited
HSC
1596.8662(b)(1)
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Mandated Reporter Training: On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided... This requirement was not met as
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The Director stated she would have staff complete the mandated reporter training and submit proof of completion to licensing by the due date by via email or fax.
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evidenced by proof of completion of required mandated reporter training was not available for review during today's inspection for S2.This poses a potential safety risk to 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: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 06-CC-20190502095100
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: INT'L CHRISTIAN MONTESSORI ACADEMY OF NEWPORT
FACILITY NUMBER: 304370185
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2019
Section Cited
CCR
101216(g)(1
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PERSONNEL REQUIREMENTS: All personnel, including the licensee, administrator and volunteers, shall be in good health. Good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than 1 year prior to or 7
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The director will arrange for staff to complete and provide a health screening. Director will provide proof of health screening to the Department by due date via email/mail.
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days after employment. The health screening shall have a health-screening report signed by the person performing the screening. This requirement was not met as evidenced by S5 missing a health screening. This posses a potential health risk to children in care.
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Type B
05/31/2019
Section Cited
HSC
1597.622
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Immunizations. A person shall not be employed or volunteer at a day care center home if he or she has not be immunized against influenza, pertussis, and measles. This requirement was not met as evidenced by missing immunizations for S2, S3, S4, S5, S7, S9.This poses a potential health risk to children in care.
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The director stated she will obtain proof of immunizations/immunity for all identified staff and proof will be sent to our office by e-mail, fax, or mail by the due date.
HSC
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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: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 06-CC-20190502095100
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: INT'L CHRISTIAN MONTESSORI ACADEMY OF NEWPORT
FACILITY NUMBER: 304370185
VISIT DATE: 05/08/2019
NARRATIVE
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page 2

This requirement was not met as evidenced by incomplete staff files for S2, S3, S4, S5, S7, S9 (see LIC 811 confidential names list dated 5/8/19) Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division & Chapter 12) Section 101216 (g)(1), H&S code 1597.622 , and 1596.8662(b)(1), is being cited on the attached LIC 9099D.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Licensee 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. Licensee was provided a copy of their appeal rights (LIC 9058 01/16), and (LIC 811 dated 5/8/19) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov



SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 4