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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300610643
Report Date: 02/20/2025
Date Signed: 02/20/2025 10:33:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2024 and conducted by Evaluator Archibaldo Silva
COMPLAINT CONTROL NUMBER: 06-CC-20241205144934
FACILITY NAME:WESTPARK MONTESSORI SCHOOL OF IRVINE, INC.FACILITY NUMBER:
300610643
ADMINISTRATOR:JENNIFER EADYFACILITY TYPE:
830
ADDRESS:11 SAN LEANDROTELEPHONE:
(949) 262-0500
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY:32CENSUS: 25DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer EadyTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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The one year old classroom is constantly out of ratio.
INVESTIGATION FINDINGS:
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On 2/20/2025 Licensing Program Analyst (LPA) A. Silva conducted an unannounced complaint investigation inspection. This is a continuation of the investigation initiated on 12/9/2024. Upon arrival, the LPA met with Director Jennifer Eady and informed the Director of the purpose of the visit. A review of the Facility Personnel Report Summary shows all facility staff or individuals who require caregiver background checks have received a criminal record clearance and a child abuse index clearance or an exemption clearance. The census at the time of the visit was 25 infants in two classrooms. Teacher to infant ratios were as follows: 3:12 in the One-Year-Old classroom and 4:13 in the Two-Year-Old classroom. The facility was operating withing ratios and capacity.

The Department received a complaint on 12/5/2024 alleging the One-Year-Old classroom was operating out of ratio. The Reporting Party stated the One-Year-Old classroom is constantly understaffed. If one teacher needs to go on a break, the ratio is 2 teachers with 11 children. This age group needs constant supervision and when the class is out of ratio that is not always possible
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 06-CC-20241205144934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: WESTPARK MONTESSORI SCHOOL OF IRVINE, INC.
FACILITY NUMBER: 300610643
VISIT DATE: 02/20/2025
NARRATIVE
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On 12/9/2024, the LPA interviewed nine facility staff. Three staff disclosed the One-Year-Old classroom had operated out of ratio for a few minutes at a time multiple times per day while a staff assigned to the classroom took a break. The LPA asked staff in the One-Year-Old classroom if they had operated out of ratio in the recent past. Staff #2 (S2) said, “Yeah, during restroom breaks.” S3 disclosed that their breaks are 15 minutes each and added that “for like 45 we operate out of ratio” as each staff takes 15-minute breaks. S4 stated that during the day they “are out of ratio for a little bit, but no longer than six minutes” when staff make a restroom run during classroom activities. The rest of the staff denied the allegation was true.

On 12/9/2024, the LPA obtained staff and children’s attendance sheets for the One-Year-Old classroom. The records show 9 children were present on 11/25, 11/27, and 12/9 and 10 on 12/2/2024. The staff attendance sheets show that 3 full-time staff assigned to the One-Year-Old classroom were present on 11/25, 11/27, and 12/2/24 (the facility administration did not provide staff attendance records for 12/9/24). Additional full-time staff assigned to all classrooms were present on 11/25 and on 12/2/24. Part-time staff assigned to all classrooms were also present on 11/25, 11/27, and 12/2/24 during the morning or afternoon shifts. While additional staff assigned to all classrooms were present those days, the records didn’t show whether the staff assigned to all classrooms covered restroom breaks in the One-Year-Old classrooms.

On 2/7/2025The LPA called seven parents requesting an interview. Parent P7 was interviewed and did not provide any information that could corroborate the allegation. The rest of the parents couldn’t be reached or did not return the Department’s request for an interview.

Children were not interviewed because they were non-verbal due to their young age.

Based on the interviews conducted with the facility staff, the preponderance of evidence standard has been met, therefore the above allegation that the One-Year-Old classroom was operating out of ratio is found to be SUBSTANTIATED. A substantiated finding means that the complaint is substantiated and the allegations are valid.

Continue on page 3.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 06-CC-20241205144934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: WESTPARK MONTESSORI SCHOOL OF IRVINE, INC.
FACILITY NUMBER: 300610643
VISIT DATE: 02/20/2025
NARRATIVE
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Page 3

California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101416.5 (b) Staff-Infant Ratio, Type A was cited on the attached LIC 9099D. Please refer to attached 9099D for the plan of correction.

Director Eady was informed that this licensing report dated 2/20/2025 documents one “Type A” citation. Type A citation(s) must be posted for 30 consecutive days during the hours that children are in care as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. LPA A. Silva further informed the director that a copy of this licensing report must be provided to parents or guardians of all clients currently enrolled by the next business day or by the next day the children are in care, a copy of this report must be provided to the parents or guardians of all newly enrolled clients for 12 months from the date of this report, and signed Acknowledgement of Receipt of Licensing Report (LIC 9224) form, or another written equivalent statement, must be placed in the child's file for verification of receipt of the report.

An exit interview was conducted with NAME LAST NAME. The Notice of Site Visit was posted during the visit. The director was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First-level appeals should be sent to the regional manager to the address listed above.

END.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 06-CC-20241205144934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WESTPARK MONTESSORI SCHOOL OF IRVINE, INC.
FACILITY NUMBER: 300610643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
101416.5(b)
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101416.5(b) Staff-Infant Ratio. There shall be a ratio of one teacher for every four infants in attendance.

This requirement is not met as evidenced by:
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The CCC owner stated administration will have a meeting with the staff to train them to notify the front office before anyone leaves the classroom so that the additional staff on site can step in the classroom to cover ratios.
The administration will send a staff attendance sheet to the LPA to confirm the meeting happened.
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Based on interview statements, three out of nine staff disclosed the One-Year-Old classroom operated out of ratio with two staff for more than 8 infants while staff took breaks. This poses an immediate risk to the health, safety, or personal rights of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4