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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371150
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:52:23 PM

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 MESAFACILITY NUMBER:
304371150
ADMINISTRATOR:KIMBOUGH, KARIFACILITY TYPE:
830
ADDRESS:2950 MCCLINTOCK WAYTELEPHONE:
(714) 966-0303
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:24CENSUS: 16DATE:
08/20/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Carrie Walker TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Hawkins arrived at the facility on 8/20/21 at 11:50 a.m. for the purpose of conducting a proof of correction inspection. LPA met with teacher Carrie Walker and a tour of the facility was completed by LPA. There were 16 children present (9 infants, 7 toddlers) with 5 staff providing supervision. A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The purpose of the inspection was to verify a proof of correction citation for the facility operating over ratio that was issued on 8/11/21. LPA reviewed facility roster, and observed 16 children (9 infants, 7 toddlers) in the yellow and orange room. Director has provided an outline of staff training that included supervision and ratio guidelines (emailed 8/12/21).
The plan of correction was verified by LPA and proof of correction letter was provided to teacher Carrie Walker during todays inspection.
In the areas that were evaluated, No deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.
An exit interview was conducted with teacher Carrie Walker in english. Appeal Rights were explained. The facility representative was provided a copy of 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 Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The
End of Report.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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