304370344-5-29-2019-06-CC-RLOZ-BENS8X-20190802133953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304370344
Report Date: 05/29/2019
Date Signed: 05/29/2019 04:11:59 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-20190502101845

FACILITY NAME:	INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESA		FACILITY NUMBER:	304370344
ADMINISTRATOR:	MAIDA, CECILE		FACILITY TYPE:	850
ADDRESS:	2950 MCCLINTOCK		TELEPHONE:	(714) 966-0303
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	41	CENSUS: 39	DATE:	05/29/2019
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Cecile Maida		TIME COMPLETED:	03:00 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 2 preschool staff, 39 napping preschool children in classroom red and blue.
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 6 staff files, interviewed 1 staff and toured facility.
During investigation and file review it was discovered that S3 file was missing the required test for tuberculosis, and S2 file test for tuberculosis was not administered within one year of hire.

Based on file review conducted, the facility failed to maintain complete staff files which should include test for tuberculosis. continued on page 2

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20190502101845

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 COSTA MESA	FACILITY NUMBER: 304370344
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/29/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2019 Section Cited CCR 101216(g)(1)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	The director will arrange for staff to complete and provide a proof of TB test. Director will provide proof of test to the Department by due date via email/mail.
	8 9 10 11 12 13 14	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 S3 has no record of TB test and S2 TB was given in 1996. This posses a potential health risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20190502101845

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 COSTA MESA	FACILITY NUMBER: 304370344
	VISIT DATE: 05/29/2019

NARRATIVE

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This requirement was not met as evidenced by incomplete staff files for S2 and S3 missing TB test (see LIC 811 confidential names list dated 5/29/19) 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) 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 5/29/19) 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 Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2019

LIC9099 (FAS) - (06/04)

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