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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371150
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:47:42 PM


Document Has Been Signed on 10/14/2022 05:47 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 MESAFACILITY NUMBER:
304371150
ADMINISTRATOR:KARI KIMBROUGHFACILITY TYPE:
830
ADDRESS:2950 MCCLINTOCK WAYTELEPHONE:
(714) 966-0303
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:24CENSUS: 15DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Director, Maria Teel TIME COMPLETED:
06:00 PM
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Licensing Program Analysts (LPAs) Dianna Valdez Santana and Patricia Duron conducted an on-site inspection for the purpose of a Case Management Incident Inspection on 10/14/22. LPAs toured the facility inside and outside, and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 15 children and 5 staff. Today's Case Management inspection is being conducted in response to a self-reported incident, reported to the OC CCL office on 10/13/22, detailing a child #1 (see Confidential Names List LIC811), had wandered out of the facility. It was reported that the facility staff may have lacked supervision allowing the child to exit the facility.

During the inspection, LPAs interviewed four staff directly involved in the incident, and child #1 (c1) could not be interviewed due being non-verbal, as well as inspected the possible path c1 may have taken to exit facility. LPAs reviewed the Incident Report with facility representative as well as the response of the facility. From the information LPAs gathered during this inspection, LPAs determined at this time further investigation is needed. Exit interview conducted with director and notice of site visit posted by LPA at entrance of facility. Notice of site visit is to remain posted for no less than 30 days. Failure to post will result in Civil Penalties of $100.00.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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