<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606148
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:04:07 PM

Document Has Been Signed on 09/27/2022 03:04 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 ORANGEFACILITY NUMBER:
300606148
ADMINISTRATOR:EMBRADOR, ALLISONFACILITY TYPE:
850
ADDRESS:1539 MAYFAIRTELEPHONE:
(714) 997-8242
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 14DATE:
09/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shirani Senayake, DirectorTIME COMPLETED:
03:15 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
On 09/27/2022, Licensing Program Analyst (LPA) Tran conducted an unannounced case management to discuss deficiencies. LPA Tran met with Director Shirani Senayake and informed the Director purpose of the visit.

Observed at the time of the visit was a total of 14 children and 4 staff members. A review of staff criminal clearance 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.

During staff interviews and record review on 08/09/2022 and 08/31/2022, it was discovered that facility failed to notify the Department of a child's unusual incidents and did not take appropriate steps in addressing child's continual misbehaviors as stated in the Parent's Handbook, which includes a conference will be held with parents, teacher and Director.

Based on LPA's interviews with staff on 08/09/2022 and on 08/31/2022 and record review of facility's Parent Hand Book, the following deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101212 (d)(1)(C) Reporting Requirement and 101173 (d) Plan of Operation. The deficiencies are being cited on the attached 809D.

Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Director Shirani Senayake.

(End of Report)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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 2
Document Has Been Signed on 09/27/2022 03:04 PM - It Cannot Be Edited


Created By: Nguyen K Tran On 09/27/2022 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: INT'L CHRISTIAN MONTESSORI ACADEMY OF ORANGE
FACILITY NUMBER: 300606148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited
CCR
101212(d)(1)(C)

1
2
3
4
5
6
7
101212 Reporting Requirement (d) Upon the occurrence...a report shall be made to the Department...(C) Any unusual incident that threatens the physical or emotional health or safety of any child.
This requirement is not met evidenced by:
1
2
3
4
5
6
7
Director stated that she would submit a statement of understanding the regulation and a plan to ensure the regulation are being followed, by due date.
8
9
10
11
12
13
14
Based on interviews and record review on 08/09/2022 and 08/31/2022, it was discovered that facility failed to notify the Department of a child's unusual incidents.
8
9
10
11
12
13
14
Type B
10/10/2022
Section Cited
CCR101173(d)

1
2
3
4
5
6
7
101173 Plan of Operation (d) The child care center shall operate in accordance with the terms specified in the plan of operation.
This requirement is not met evidenced by:
1
2
3
4
5
6
7
Director stated that she would submit a statement of understanding the regulation and a plan to ensure the regulation are being followed, by due date.
8
9
10
11
12
13
14
Based on interviews and record review on 08/09/2022 and 08/31/2022, it was discovered that facility failed take appropriate steps in addressing child's continual misbehaviors as stated in the Parent's Handbook.
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:Rina Lopez
LICENSING EVALUATOR NAME:Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2