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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270541
Report Date: 07/16/2026
Date Signed: 07/16/2026 11:56:38 AM

Document Has Been Signed on 07/16/2026 11:56 AM - 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: 58CENSUS: 41DATE:
07/16/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH:Facility Representative, Priyangani EdiriwiraTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 07/16/2026, Licensing Program Analyst (LPA) Deschampe arrived at 9:32AM and conducted an unannounced Plan of Correction (POC) inspection in response to the Type B violations issued on 04/17/2026 and 04/24/2026: California Code of Regulations (CCR) Section 101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. CCR Section 101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time,...Supervision shall include visual observation. CCR Section 101216.3 Teacher-Child Ratio (a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance,... CCR Section 101221 Child's Records (b) Each record shall contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications. CCR Section 101239 Fixtures, Furniture, Equipment and Supplies (a) A comfortable temperature for children shall be maintained at all times. (1) The licensee shall maintain the temperature in rooms that children occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

LPA was allowed entry by the facility representative (FR), Priyangani Ediriwira. LPA explained the purpose of the inspection. Census was taken as LPA was guided through the facility by the FR. Total enrollment is 58 children. At the time of census, there were 41 children with 7 staff. Current census due to alternate children schedules.

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2026
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: 07/16/2026
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Page 2 (POC)

A review of staff criminal clearance record on this date 07/16/2026 indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or approved exemptions.

The deficiencies that were cited on the LIC 9099D and LIC809D on 04/17/2026 and 04/24/2026 have been cleared through LPA observation, interview, and record review.

On 02/19/2026, the facility reviewed CCR Section 101223 Personal Rights with staff.

On 04/20/2026, the facility completed a staff in-service for: New Nap Time Procedure and alternative activities for children who do not nap (documentation on file), staff training included reading the articles "What's considered challenging behavior in early childhood?", information regarding Mandated Reporters, and "When to seek professional support for challenging behaviors."

On 07/16/2026, FR stated additional staff have been hired to meet teacher to child ratio and supervision regulations. LPA reviewed the updated Personnel Report (LIC500), including staff scheduling, and new hire staff files. LPA gave FR a copy of the CCR Section 101216 Personnel Requirements. LPA observed classrooms in compliance with staff to children ratio and maintenance of visual supervision of children in care. LPA observed prescribed medication and medical documentation in compliance.

On 05/01/2026, FR completed a staff in-service to review classroom temperature, per CCR 101239(a)(1). LPA observed all classroom temperature in compliance with CCR.

Based on LPA's observations, interviews, and records reviewed during this visit, the violations which were cited on 04/17/2026 and 04/24/2026, are cleared.

Exit interview conducted and report was reviewed with the facility representative, Priyangani Ediriwira. The Notice of Site Visit was posted during the visit. A notice of site visit was given and must remain posted for 30 days.

End of report.

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

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
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