304370344-7-12-2022-06-CC-PRIS-CG9RR7-20220712131440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370344
Report Date: 07/12/2022
Date Signed: 07/12/2022 01:14:45 PM

Document Has Been Signed on 07/12/2022 01:14 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
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
ADMINISTRATOR:	KARI KIMBROUGH		FACILITY TYPE:	850
ADDRESS:	2950 MCCLINTOCK WAY		TELEPHONE:	(714) 966-0303
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	41	CENSUS: 24	DATE:	07/12/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Teel, Director		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) P Rivas conducted an unannounced case management visit for an incident that occurred on 05/11/22 on the playground. Prior to entering facility LPA reviewed Covid 19 Questionaire to determine appropriate PPE equipment. Upon entrance LPA toured facility and took census. Under this license there are two rooms assigned, the Red room that had 14 children and 2 teachers and the PreK room that had 2 teachers and 12 children. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Facility Day Care hours are 7:30 am-5:30pm, Monday through Friday. LPA was also advised that a new Director Packet was submitted by former Director For Ms. Maria Teel. LPA advised to provide follow-up packet to LPM J. Hanson. Facility reported that on 05/11/22 at approximately 10:45 am Child #1(C1) got stuck on playground equipment between a wooden slate and a iron bar. LPA was informed on the day in question on the playground there were 2 teachers and 18 children; within ratio. LPA reviewed wooden playground structure and found it to have no sharp edges, well maintained and free of hazards. The height of the equipment (portion in question) from base to bar is 35 inches, the space from wood to bar is 9 inches; C1 is approx 3feet 5 inches and 7 inches wide. During today's visit LPA interviewed two staff and two children. Interview with Staff #1(S1) indicated prior to going into yard children are told not to climb equipment. S1 also stated they were caring for other children and Cont. Page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/12/2022

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when they got to C1 , C1 had already been taken down the playground equipment by S 2 and S3. Interview with S2 indicated they assisted S3 in getting child down from playground equipment. S2 indicated C1 was panicking and had made it difficult for S3 to bring C1 down alone so S2 assisted in bringing C1 down. S2 stated the space between the wooden slate and the iron bar was more than sufficient for child. LPA was unable to interview S3 they were on vacation. Interview with C1 divulged that they were climbing the equipment and got stuck but that S3 helped them right away, C1 further indicated they hurt their back and cried. Interview with C2 indicated C1.... "was climbing the bars, and was crying but teachers helped(c1)"

Based on interviews conducted, review of records and review of playground equipment no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Appeal Rights were discussed with Ms. Teel A notice of site visit was given and must remain posted for 30 days.Posting Requirements Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Director, Ms. Teel.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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