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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270541
Report Date: 04/17/2026
Date Signed: 04/17/2026 04:19:46 PM

Document Has Been Signed on 04/17/2026 04:19 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:BACK BAY MONTESSORIFACILITY NUMBER:
304270541
ADMINISTRATOR/
DIRECTOR:
PRIYA EDIRIWIRAFACILITY TYPE:
850
ADDRESS:398 UNIVERSITY DRIVETELEPHONE:
(949) 548-3771
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 67TOTAL ENROLLED CHILDREN: 66CENSUS: 28DATE:
04/17/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Facility Representative, Priyangani EdiriwiraTIME VISIT/
INSPECTION COMPLETED:
04:34 PM
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In conjunction with the other inspections, Licensing Program Analyst (LPA) Deschampe conducted a case management due to a deficiencies identified during an inspection on 02/24/2026. On 04/17/2026, LPA informed the facility representative/director (FR), Priyangani Ediriwira about the purpose of the case management inspection. At 8:30 AM, LPA met with the FR who guided LPA through facility to obtain census. The total enrollment is 66 children and due to various student schedules, census taken was 28 children and 5 staff.

During the staff interview, Staff 1 (S1) disclosed on 02/24/2026 around 2:30 – 2:50PM, S1 witnessed Child 1 (C1) was left outside alone, without adult supervision. S1 did not know how C1 got out to the playground. S1 told Staff 2 (S2) that C1 was left outside alone, without adult supervision, and S2 did not know how C1 got out to the playground. C1 was fine sitting in the middle of the table (pictures taken) outside when S1 found C1.

S2 stated the following: On 02/24/2026, C1 had left the room around 2:40 PM and gone outside with their bag. C1 had apparently walked out when a parent opened the door and gone outside. S2 admitted S2 did not see C1 leave the classroom and was outside alone for approximately 10 – 15 minutes.

S5 stated the following: S5 stated there was no child outside when S5 walked from the classroom to the office building. When S5 was walking from the office to the classroom, C1 was found alone, without adult supervision, in the outdoor play area and C1 was brought to staff.

Staff 3 (S3) disclosed witnessing Staff 4 (S4) leaves children without adult supervision, in the outdoor playground area, on a regular basis. S3 stated S4 has been found in the break room while S4’s class are on the playground in the afternoon hours, often after 3:00 PM.

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BACK BAY MONTESSORI
FACILITY NUMBER: 304270541
VISIT DATE: 04/17/2026
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On 04/17/2026, FR guided LPA on a tour of the facility, LPA witnessed at approximately 12:31 - 12:36 PM, Staff 6 (S6) in the doorway of the bathroom and classroom 2. S6 had their back turned toward Classroom 2, while watching children wash their hands. LPA and FR walked through the bathroom and observed there was not a staff member in Classroom 2. Classroom 2 had 21 preschool children. 4 out of 21 children were not napping. S6 was with 2 children in the adjoining bathroom and left the remaining children without supervision, for approximately 2 minutes until another staff member helped the children in the bathroom. This incident was witnessed, discussed, and addressed with the FR, immediately.

After the inspection, the following deficiencies were observed and cited in accordance with the California Code of Regulations (CCR) Title 22, Division 12, Chapter 1 of Child Care Centers. Please refer to attached 809D for documentation of deficiencies.

CCR Section 101229(a)(1) Responsibility for Providing Care and Supervision

CCR Section 101216.3(a) Teacher-Child Ratio

Exit interview conducted and report was reviewed with the facility representative/director (FR), Priyangani Ediriwira. Appeal Rights were discussed with facility representative. The facility representative was provided a copy of the 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 consecutive days. The “Notice of Site Visit” must be posted on, or immediately adjacent to, the interior side of the main door to the facility. Failure to post will result in Civil Penalties of $100.00.

End of Report

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2026 04:19 PM - It Cannot Be Edited


Created By: Susan Deschampe On 04/17/2026 at 12:21 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: BACK BAY MONTESSORI

FACILITY NUMBER: 304270541

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2026
Section Cited
CCR
101229(a)(1)

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101229 (a)(1) Responsibility for Providing Care and Supervision...No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation.
This requirement was not met as evidenced by:
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FR will make staff schedule changes.
FR will have a plan with appropriate alternatives to children who do not nap.
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Based on staff interviews and LPA observation, S2 admitted to not knowing C1 was in the outdoor playground alone. S2 & S5 witnessed C1 alone in the outdoor playground. This poses a potential risk to the safety of the children in care.
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Type B
05/15/2026
Section Cited
CCR101216.3(a)

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101216.3Teacher-Child Ratio. (a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children...
This requirement is not met as evidence by:
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FR will adjust staff schedules.
FR will update classroom plan.
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LPA observation: LPA observed on 04/17/26, S6 had 17 out of 21 children napping. This poses a potential risk to the safety of the 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.
Thuy Ho
NAME OF LICENSING PROGRAM MANAGER:
Susan Deschampe
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
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