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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371528
Report Date: 09/17/2021
Date Signed: 09/17/2021 12:40:17 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:HERITAGE MONTESSORI SCHOOLFACILITY NUMBER:
304371528
ADMINISTRATOR:TOVAR, SAMANTHAFACILITY TYPE:
850
ADDRESS:2032 ORANGE AVENUETELEPHONE:
(949) 764-9433
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:90CENSUS: 52DATE:
09/17/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Ms. Tovar, Samantha TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Ms. Ketki Desai conducted an announced on site pre-licensing inspection at the childcare center. It is a Change of Ownership. Facility was given an Emergency Approval to Operate which is valid up to September 29th 2021.
LPA met with Facility Administrator Ms. Tovar Samantha, who gave a tour of the Child Care Center. The applicant has requested to provide care and supervision for 90 Preschool age children (2- 6 years Monday through Friday 7.30 am. to 5.30 PM. in the assigned three classrooms and one additional resource room. Due to COVID 19, LPA observed staff wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines.
A review of the Facility Personnel Report Summary 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.

The facility has an Elementary school (Classroom # 4) on the same premises and the access to the classroom is through the Resource room. Due to current pandemic situation, Parents are encourage to follow CDC and COVID requirements, children are dropped off and picked up at the curb end (Parents park their car in front of the small wooden gate, staff checks the temperature of the child, a visual check in done, parents sign off the child manually before the child is off loaded from the car and walked into the assigned classrooms. Hand washing activity is completed before the child engages in other classroom activities.

Initially before COVID, children were received in the front area ( across the DIrector's office) and children would enter the designated classroom. Parents are encouraged to remain outside. The office area is located in front of the main entrance door of the facility, adjoining to it is the Resource room which has a dining table / Refrigerator and a sink / Teachers use this area during their break time , adult bathroom is in front of the Director's office. (Page-1)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
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: HERITAGE MONTESSORI SCHOOL
FACILITY NUMBER: 304371528
VISIT DATE: 09/17/2021
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Medication are stored in the Resource room, in a red medication box along with the forms which are hung on the wall and this area is immediately accessible from all the three classrooms. Medications shall be administered by the teacher or the Facility in charge, emergency First Aid kits are stored in the classrooms and are hung on the wall for immediate access. Medication administration forms were reviewed.
Isolation area is the Director’s office and the sick child shall use the adult restroom located in front of the DIrector's office area, there is an additional mat and linens for the sick child.

The following were inspected in the indoor activity space:
· Classrooms are adequately equipped with age and size appropriate furniture and equipment
· Drinking water is available inside through personal water bottles including water pitchers in each rooms
· Sign in/Sign out procedure was reviewed and meets regulation requirements (Manual sign in and out)
· There is a working smoke detector, carbon monoxide detector and fire extinguisher that meet statutory requirements.
· Cubbies available for storage of individual child’s personal belongings and/or bedding
· Napping equipment: Mats are used and are stored in the storage area (Inside the bathroom), napping linens and blankets are provided by parents and are taken home daily for the washes
· Facility shall provide Two snacks and a late evening snack, Lunch is provided by the parents.
Kitchen was observed to clean, free of insects or pests. There one refrigerator with freezer, where snacks are stored
Each classroom is equipped with age appropriate sinks and toilets.

LPA discussed the posting requirements including, but limited to, the following:
· Facility License in public area (101160)
· Emergency Disaster Plan (LIC 610) /
Earthquake Preparedness Check List (LIC 9148)
· Parents’ Rights Poster (PUB 393) / Personal Rights (LIC 613A)
· Menus / Activity Schedule
· Notice of Site Visit (LIC 9213) and Type A deficiencies / Plan of Corrections of Type A deficiencies
· Granted Waivers (available for review)
· Child Car Seat Law (PUB 269) and COVID Posters (Page-2)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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: HERITAGE MONTESSORI SCHOOL
FACILITY NUMBER: 304371528
VISIT DATE: 09/17/2021
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Facility has several operating options : Morning care : 7.30 am to 8.40 am (Monday to Friday)
Five full day sessions : 9.00 am to 2.30 PM / Half Day sessions : 9.00 am to 12.00 PM / Three day Full day sessions and Extended evening care : 2.30 PM to 5.30 PM (Evening snack shall be provided by the facility)

On today's inspection, LPA measured Indoor and Outdoor areas used by the children.
Indoor measurements:
ROOM IDENTIFICATION LENGTHWIDTH
AREA
ENCUMBERED
SPACE
Room 1 (Big area)
32
18.42
589.44
72.66
516.78
Room # 1 ( small area)
24.58
23.25
571.49
571.49
Room # 2 (Big area )
26.33
25
658.25
55.91
602.34
Room #2 (small area)
26
14.67
381.42
55.44
325.98
Room # 3
43.92
22.33
980.73
85.33
895.40
Resource room (Dining area)
26.83
16.17
433.84
70.54
363.30
Resource room (small area)
23.67
11
260.37
260.37

Total Indoor activity space: 3535’66 divided by 35 Sq Ft = 101’02 (101 children)

Total sinks: 9 X 15= 135 (children) / Total Toilets: 6 X 15= 90 (children)


There are sufficient toilets and sinks in the facility to meets the needs of the requested capacity for 90 children

Toilets and sinks were observed to be age appropriate. Bathrooms were clean and accessible to children. Each classrooms has two sinks and two toilets in the bathroom. (Room 1 has 3 sinks) There is an additional storage room inside the bathroom where mats are stored, inaccessible to children.

Facility also uses the additional Resource room for indoor activity time, the room is also used by the teacher during the absence of the children. It is open and well lighted. The carpet area is used during story telling time and also during rainy days or cold winter days, the room is used for additional indoor activities. It is accessible from each room.

(Page-3)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: HERITAGE MONTESSORI SCHOOL
FACILITY NUMBER: 304371528
VISIT DATE: 09/17/2021
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Outdoor Yard:
The following were inspected in the Outdoor activity space;
Facility has several yards : Front yard and Back yard with Tree house area/ Barn area and Boat deck area.
· Playground is fully enclosed by an appropriate fencing
· Drinking water is available outdoors by water pitchers with small disposable cups/ Water fountain/ Personal Water bottles
· Outdoor activity space is supplied with age and size appropriate equipment, including climbing play structures and outdoor activity toys,
· An adequate amount of cushioning material consisting artificial grass / cushion mat is placed to absorb the falls.
There is one sink in each of the yard.
· Adequate shade is provided by shaded structure (Canopy)and benches are placed.
· Each classrooms have their own entrance leading into their yards.
Barn area and garden area are used for Science experiments and Harvesting activity is also done here
Facility has requested a Waiver for a Shared yard with Staggered schedule for Preschool children to share yard with the Elementary school on the premises.

Outdoor measurements
AREA IDENTIFICATION LENGTH WIDTH
AREA
ENCUMBERED
SPACE
Front yard
120.42
63.08
7596.09
7596.09
Back yard (Tree house area)
100.5
63
6331.50
55.44
6276.06
Back yard (Barn Area)
57.33
44.83
2570.10
2570.10
Back Yard: Boat deck area
30.75
21.75
668.81
668.81

Total outdoor space: 17111’07 divided by 75 = 228’15 (228 children)

Based on the indoor and outdoor measurements, sink and toilet availability, facility has enough space to accommodate the requested 90 Preschool children ( 2-6 years old) in the assigned Three classrooms and the Resource room. (Page-4) .

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: HERITAGE MONTESSORI SCHOOL
FACILITY NUMBER: 304371528
VISIT DATE: 09/17/2021
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Fire clearance received from City of Costa Mesa Fire prevention office dated 9/01/21 have approved the requested capacity of 90 Preschool age children in the assigned three rooms and the Resource room.
Room # 4 is the Assigned Elementary school which is also approved by the Fire Prevention office during inspection.

Facility Administrator is current on the required Immunization/ Pediatric CPR/ First training valid through
8/22/23 and have provided the completion certificate for the Preventive Health training (Nutrition and Lead component)

Water Analysis has been completed by the facility and the report is on file.

LPA, discussed with the applicant that all employees must have criminal record clearances associated to the facility prior to their presence in the facility, staff to child ratio requirements, direct visual supervision requirements, emergency/disaster drills, children records, mandated reporter training, and staff immunization requirements against measles, pertussis, and influenza. Applicant was advised the children's bedding must be stored individually and may not touch another children's bedding.

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to down load forms, Title 22 regulations, and training's on-line at www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. or at www.ccld.ca.gov

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian.
Facility Director has access to the new system. (Page-5)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: HERITAGE MONTESSORI SCHOOL
FACILITY NUMBER: 304371528
VISIT DATE: 09/17/2021
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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 applicant/facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness

Incidental Medical Services : This facility plans to provide the services. IMS plan was submitted and
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

The facility was following Title 22 requirements at the time of the inspection. Based on today’s Indoor and Outdoor measurements, sink and toilet availability, this center has enough activity space to support the capacity of 90 Preschool children, ages 2-6 years old in Room # 1,2, 3 and Resource room. A license will be issued for the capacity of 90 preschool children age 2-6 years old, after a final review. The applicant will be notified if any additional information is required.

Applicant was also advised, once licensed, the Notice of Site Visit must be posted for 30 days and if A violations are cited then the Licensing Report (LIC809 or 9099) must be posted by the Notice of Site Visit for a period of 30 days or $100 civil penalties will be assessed, and the report shall posted and copies provided to the parents/guardians of the children in care at the facility by the next business day,and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The applicant was provided a copy of their appeal rights (LIC 9058 12/15) 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.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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