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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270294
Report Date: 08/30/2023
Date Signed: 08/30/2023 12:25:46 PM

Document Has Been Signed on 08/30/2023 12:25 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:NORTHWOOD MONTESSORI SCHOOL OF IRVINEFACILITY NUMBER:
304270294
ADMINISTRATOR:FUKUNAGA, LISAFACILITY TYPE:
850
ADDRESS:12100 YALE COURTTELEPHONE:
(714) 508-0400
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 174TOTAL ENROLLED CHILDREN: 174CENSUS: 104DATE:
08/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lisa Fukunaga - DirectorTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Odom conducted a Case Management report during an annual inspection. LPA met with Director Lisa Fukunaga, during the annual inspection LPA obtained a copy of the Lead Sampling testing conducted on 01/07/23. Director stated they posted the Lead Sample Report on the parent board when they received the lead report.

Director stated the outlets with high levels of Lead was inoperable. Outlet B is a drinking fountain in Rm #1 that was closed off by shutting off the water outlet. Director stated the outlet was replaced with a new drinking fountain and it was retested on 06/21/23. Source of drinking water is children’s water bottles brought from home and refilled by staff using pitchers with filtered water from the water dispenser located in the kitchen.

Based on LPAs record reviews the following violation was observed and is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 3, Section 101700.3 California Lead Action Level at Child Care Centers is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the Director Lisa Fukunaga. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) 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. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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Document Has Been Signed on 08/30/2023 12:25 PM - It Cannot Be Edited


Created By: Carmen Odom On 08/30/2023 at 11:56 AM
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: NORTHWOOD MONTESSORI SCHOOL OF IRVINE
FACILITY NUMBER: 304270294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2023
Section Cited

101700.3(b)(1)

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Division 12, Chapter 1, Subchapter 5
101700.3 California Lead Action Level at Child Care Centers (b) Testing... Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
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Director stated they already remediated Outlet B, by replacing an new drinking faucet and retesting the outlet on 6/21/23. The test results came back negative. LPA obtained a copy of the lead test results.
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Based on facility Lead sampling tests it was discovered that outlet B in Rm 1 had high level of lead. This poses a potential risk to the health 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.
SUPERVISOR'S NAME:Judy Hanson
LICENSING EVALUATOR NAME:Carmen Odom
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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