304371063-5-23-2023-06-CC-DTHN-CS4NQN-20230523104012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371063
Report Date: 05/23/2023
Date Signed: 05/23/2023 10:40:23 AM

Document Has Been Signed on 05/23/2023 10:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	LAKE FOREST MONTESSORI SCHOOL		FACILITY NUMBER:	304371063
ADMINISTRATOR:	SHAMA, RICHA		FACILITY TYPE:	830
ADDRESS:	25435 TRABUCO ROAD		TELEPHONE:	(949) 951-2862
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	18	CENSUS: 3	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Richa Shama		TIME COMPLETED:	11:00 AM

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) Thompson conducted an onsite inspection for the purpose of an Annual Random. LPA toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. Census was taken inside the classroom. LPA observed was 3 infants with 2 staff. Facility hours are Monday through Friday, 7:00 AM to 6:00 PM. LPA met with Director Richa Shama. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Upon entry into the infant center, LPA observed Child #1 (C1) swaddled and strapped down inside a swing while sleeping. While LPA was taking pictures, LPA observed staff #1 (S1) removing blankets, unstrapping C1, then removing C1 from the swing and placing C1 inside a crib. 101430(a)(3)(C) An infant shall not be swaddled while in care. 101430(a)(3)(E) If an infant falls asleep before being placed in a crib, staff shall move the infant to a crib as soon as possible. In 2019, a citation was issued for the same regulation. The Director stated that the swings are not normally used as napping equipment, and the infants are normally moved to a safe napping arrangement once they are to fall asleep. During the inspection of the indoor activity space, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications or hazardous items). All storage containers for solid waste, including moveable bins, have tight fitting covers that are kept on and are in good repair. Bottles and containers of food brought by the infant’s authorized representative are labeled with the infant’s name and current date. Continue to page 2

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LAKE FOREST MONTESSORI SCHOOL	FACILITY NUMBER: 304371063
	VISIT DATE: 05/23/2023

NARRATIVE

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The facility has conducted an emergency drill within the past six months, last drill conducted on 11/2022. The facility has a working carbon monoxide detector and fire alarm. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

The facility has an indoor activity space for infants that is physically separate from space used by preschool age children.

Staff files were reviewed for staff present during the facility inspection this date; 2 staff files were reviewed. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for 2 staff were reviewed and within compliance

Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Staff present inside infant program possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 8/12/2024.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of children files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. LPA reviewed the napping log for infants up to 24 months and LIC 9227 Infant Safe Sleep Plan for infants up to 12 months. In the areas reviewed, the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance.

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LAKE FOREST MONTESSORI SCHOOL	FACILITY NUMBER: 304371063
	VISIT DATE: 05/23/2023

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov director may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The director was informed, and website given, about the California Child Care Disaster Planhas been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness

LPA discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

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SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LAKE FOREST MONTESSORI SCHOOL	FACILITY NUMBER: 304371063
	VISIT DATE: 05/23/2023

NARRATIVE

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Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

In the areas that were evaluated, Care and Supervision - Type A: 101430(a)(3)(C) and Care and Supervision - Type B: 101430(a)(3)(E) deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

LPA Thompson informed Director Richa Shama that this report dated 5/23/2023 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Thompson informed Director Richa Shama to provide a copy of this licensing report dated 5/23/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Richa Shama. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Appeal Rights were discussed. Director was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2023 10:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LAKE FOREST MONTESSORI SCHOOL	FACILITY NUMBER: 304371063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101430(a)(3)(C)

Infant Care Activities

(C) An infant shall not be swaddled while in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Upon entry into the infant center, LPA observed C1 being swaddled and strapped down inside a swing while sleeping which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Per Director, will meet with infant teachers today and discuss the Safe Sleep Guidelines and will send agenda to LPA with staff signatures by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Judy Hanson	TELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 05/23/2023 10:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LAKE FOREST MONTESSORI SCHOOL	FACILITY NUMBER: 304371063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101430(a)(3)(E)

Infant Care Activities

(E) If an infant falls asleep before being placed in a crib, staff shall move the infant to a crib as soon as possible. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. C1 was observed asleep inside a swing which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Per Director, will meet with infant teachers today and discuss the Safe Sleep Guidelines and will send agenda to LPA with staff signatures by POC due date. C1 was observed asleep inside a swing

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Judy Hanson	TELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean Thompson	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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