304371117-5-30-2019-06-CC-JMHN-BCNK6U-20190530073806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371117
Report Date: 05/29/2019
Date Signed: 05/30/2019 07:38:13 AM

COMPREHENSIVE INSPECTION

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:	MONTESSORI INTERNATIONAL ACADEMY		FACILITY NUMBER:	304371117
ADMINISTRATOR:	SUMIKAWA, SUMIYO		FACILITY TYPE:	840
ADDRESS:	1211 E. DYER RD #110		TELEPHONE:	(714) 444-2733
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	60	CENSUS: 49	DATE:	05/29/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Sumiyo Sumikawa		TIME COMPLETED:	02:20 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), Han conducted an unannounced annual/random inspection of the facility on today's date. LPA Han toured the facility with the director, Sumiyo Sumikawa inside and outside. The overall census observed was 2 preschool staff and 23 preschool children and 6 school-age staff and 26 school-age 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. Operating hours are 8:00 am- 6:00 pm, Mon-Fri. The facility’s kindergarten children are planning to have musical performance on June 5~6 with preschool children from next building facility (License number 304370799). LPA observed 23 preschool children are practicing on the stage with 26 kindergarten children with 2 preschool staff and 6 kindergarten staff. Director stated children practice together between 11AM and 12PM everyday from May 28 to June 4. The items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Lunch is delivered by 3^rdparty vendor restaurant; morning snack is provided by facility, afternoon snack is not provided. Children bring their own afternoon snack. Food prep areas appear clean and sanitary. Food is properly stored. On site kitchen is free from hazards. The toys, floors, desks and other equipment appeared clean. There is drinking water available to children both indoors and outdoors by using water pitcher. The children's bathrooms are clean and sanitary. The facility has conducted an emergency drill within the past six months. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground was completely fenced. The playground equipment appeared in safe condition. There is sufficient cushioning underneath play equipment to absorb falls. Sign in/out procedure was reviewed for compliance. Children's roster is not available to review during the inspection. Director stated she did not maintain children's roster. During today's visit staffing ratios were being met. At least one staff member present possesses current CPR/First Aid certifications, which expires 07/2020. Children's and staff files were reviewed for compliance. Children's and staff's files were in compliance.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
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.

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: MONTESSORI INTERNATIONAL ACADEMY	FACILITY NUMBER: 304371117
	VISIT DATE: 05/29/2019

NARRATIVE

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Provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

The facility representative was informed that the CRIMINAL RECORD STATEMENT (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. The facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182). The facility representative was informed that Licensing Updates are available at www.ccld.ca.gov

Documents/Information to be updated and returned to the Licensing Office;
- Personnel Report (LIC 500)
- Emergency Disaster Plan (LIC 610)
- Designation of Administrative Responsibility (LIC 308)
- Administrative Organization (LIC 309)

Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. Appeal Rights and deficiencies were discussed. The director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov

The director 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.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
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

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: MONTESSORI INTERNATIONAL ACADEMY	FACILITY NUMBER: 304371117
	VISIT DATE: 05/29/2019

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The facility does provide Incident Medical Services.
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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
LPA observed two epinephrine were expired in the medication storage. (see attache LIC 813) Director stated both children are not attending school anymore.
Based on LPAs observations, record reviews, and interviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3 Section 101226(e)(3)(A) and Health and Safety code 1596.841. Please refer to attached 809D for documentation of deficiencies. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
Always place infants on their backs for sleeping
Use only a tight-fitting sheet on the crib or play yard mattress
Do not hang any items from the crib or above the crib
Keep all items, including blankets, out of the crib or play yard
Pacifiers may be used as long as they do not have items attached to them
Infants should not be swaddled or have any items covering them while sleeping
The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
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

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: MONTESSORI INTERNATIONAL ACADEMY	FACILITY NUMBER: 304371117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/29/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/12/2019 Section Cited CCR 101226(e)(3)(A)	1 2 3 4 5 6 7	101226(e)(3)(A) Health-Related Services ...(3) Prescription medications may be administered ...(A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Director stated child#7 and child#8 are no longer attending this facility. Both children moved back to Japan. Director stated she will ensure to keep non-expired prescription medications at the facility at all times by checking every 1st day of the month.
	8 9 10 11 12 13 14	Based on observation and interview, the director failed to ensure to keep non-expired epinephrine for child#7 and child#8. Both children are terminated on each 5/4/2018 and 6/27/2018. This poses a potentical Health and Safety risk to the children in care	8 9 10 11 12 13 14	Director will submit plan statement by email to LPA by 6/12/2019. JUNGMI.HAN@DSS.CA.GOV
Type B 06/12/2019 Section Cited HSC 1596.841	1 2 3 4 5 6 7	1596.841 Current roster of children provided care in facility required. Each child day care facility s,,, current roster of children who are provided care in the facility. ...This roster shall be available to the licensing agency upon request. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Director will submit updated children's roster to LPA by 6/12/2019 by email. JUNGMI.HAN@DSS.CA.GOV
	8 9 10 11 12 13 14	Based on observation and interview, the director failed to ensure to maintain children's roster. This poses a potentical Health and Safety risk to the children in care	8 9 10 11 12 13 14

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) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
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

LIC809 (FAS) - (06/04)

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