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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370344
Report Date: 10/29/2025
Date Signed: 10/29/2025 03:05:38 PM

Document Has Been Signed on 10/29/2025 03:05 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:INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESAFACILITY NUMBER:
304370344
ADMINISTRATOR/
DIRECTOR:		MARIA TEELFACILITY TYPE:
850
ADDRESS:2950 MCCLINTOCK WAYTELEPHONE:
(714) 966-0303
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 41TOTAL ENROLLED CHILDREN: 41CENSUS: 0DATE:
10/29/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Licensee/Inayat Bergum, Business Manager/Ilana , Director/Facility Representative, Maria TeelTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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An Informal Meeting was conducted on this day, 10/29/2025 at the Orange County Regional Office. Present during the meeting were Thuy Ho, Licensing Program Manager (LPM), Susan Deschampe, Licensing Program Analyst (LPA), Inayat Bergum, Owner/Licensee, Jana Pokusa/Business Manager, and Maria Teel, Director/Facility Representative.

The purpose of this informal meeting was to discuss the following violation which was issued on 7/30/2025.

Buildings and Grounds: The child care center shall be...safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met evidenced by: Based on observation and interview, the wooden fence in the preschool play area has multiple holes from deterioration (approximately 6 inches from ground, 2-3 inches diameter), exposed rusted screws/nails and splintering wood (pictures taken), and broken cement (pictures taken).

On 08/06/2025, LPA received an email with pictures of the replaced fence and repaired concrete from the director/facility representative. On 08/13/2025, LPA completed a Plan of Correction (POC) inspection and observed the repairs. LPA issued a cleared POC letter on 08/13/2025.

The facility representatives confirmed that the safety measures outlined in the plan have been in place. Facility has a morning checklist completed by staff to assess the buildings and grounds. The evening checklist is completed by staff to assess buildings and grounds. When items need to be addressed, Lynn Lane, Maintenance Staff is contacted and completes the task.

The LPM also reviewed the Department of Social Services State of California Stipulation and Waiver Order #6622306102-B dated 04/10/2024 and the acknowledgement that Inayat Bergum, Jana Pokusa, and Maria Teel understand the conditions.

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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: INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESA
FACILITY NUMBER: 304370344
VISIT DATE: 10/29/2025
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The following were discussed in this meeting:
1. The facility representatives were advised that the facility must be in compliance at all times.
2. Increased unannounced visits to the facility will be conducted by the Department to monitor compliance.
3. The facility representatives were informed that if subsequent repeated violations are cited in the future and the Department determines that the facility has violated the laws/regulations or is inadequately implementing the approved plans to remedy the facility's noncompliance, the Department, in its discretion, will seek formal legal action.
4. Provider's Webinar: https://www.cdss.ca.gov/inforesources/child-care-licensing/resources-for-providers
5. Technical Support Program (TSP) was discussed. TSP referral flyer was provided to facility representatives. Facility staff participated in TSP on 06/28/2023. LPA to complete referral to TSP, as requested by facility representatives.

Upon receipt of this report pertaining to a meeting conducted by a local Licensing Agency in which issues of were discussed, the licensee must: 1. Provide a copy of this report to the parent/guardian of children currently enrolled by the next business day or immediately upon return. 2. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). 3. Obtain signature and date from the child's parent/authorized representative on the Acknowledgement of Receipt of Licensing Reports LIC 9224. 4. Keep a record immediately upon receipt of the completed and signed LIC 9224 acknowledging receipt of this report in the child's file.

Exit interview conducted with the Inayat Bergum, Owner/Licensee, Jana Pokusa/Business Manager, and Maria Teel, Director/Facility Representative who are in agreement with the above. A copy of this report was provided Maria Teel, Director/Facility Representative.

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

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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