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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371475
Report Date: 04/21/2021
Date Signed: 04/21/2021 12:20:13 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:BUENA PARK MONTESSORI ACADEMYFACILITY NUMBER:
304371475
ADMINISTRATOR:GUNASEKARA, HISSANKA S.FACILITY TYPE:
830
ADDRESS:6221 LINCOLN AVENUETELEPHONE:
(714) 821-7800
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:32CENSUS: 0DATE:
04/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:No one presentTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA ) Ketki Desai made an unannounced Case Management -Other inspection at the above site.
On Monday April 19th 2021, the facility was directed to cease all the operations at the site, due to denial of Fire clearance and the application was denied based on the STD 850 received.
An application denial letter was sent to the applicant directing to cease the operations immediately.

LPA, on her unannounced visit observed that the Operations were completely ceased, there was no one on the property / parking lots was empty and the gate was locked.
LPA have taken several pictures to confirm the closure and have received an email confirmation from the applicant regarding the operation closure of the facility.

Based on observations, pictures and email received, it is confirmed the operation has been ceased at the above facility.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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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