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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370495
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:14:47 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
10/04/2023 and conducted by Evaluator Aiddee Nunez
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20231004154408
FACILITY NAME:IRVINE MONTESSORI SCHOOLFACILITY NUMBER:
304370495
ADMINISTRATOR:CABRERA, RUBYFACILITY TYPE:
850
ADDRESS:17575 CARTWRIGHT ROADTELEPHONE:
(949) 752-7217
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY:197CENSUS: 59DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Director, Ruby CabreraTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility does not have an emergency disaster plan.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Aiddee Nunez conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 10/10/2023. Upon arrival LPA met with Director Ruby Cabrera, to deliver complaint findings. Census was taken in each classroom and observed a total of 5 toddler children (toddler option) with 2 staff and 54 preschool children with 9 staff.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During today’s inspection the facility was operating within its licensed capacity and within compliance of staffing ratios.

Page 1 of 3
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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-20231004154408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IRVINE MONTESSORI SCHOOL
FACILITY NUMBER: 304370495
VISIT DATE: 12/21/2023
NARRATIVE
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On 10/4/23 the Orange County Child Care Office received a complaint alleging Facility does not have an emergency disaster plan. Reporting Party (RP) stated the school is supposed to have an earthquake and fire drills monthly, an emergency backpack in every classroom, and a map of the emergency exit. RP continues stating that none of this is communicated to the employees, so the employees do not know where to go in case of an emergency.

During the investigation, LPA Nunez interviewed 7 staff members including the director, 2 parents, and 5 children. LPA also obtained a copy of the emergency disaster plan for child care center (LIC 610), a copy of the fire and earthquake drill logs, and the staff and children’s rosters. LPA Nunez also went to each classroom and inspected their first aid kit and their emergency exit plan.

On 10/10/23 LPA Nunez observed the emergency disaster plan for child care center (LIC 610) posted on the parent bulletin board. LPA Nunez observed a first aid kit in each classroom. LPA Nunez also observed an emergency exit plan posted in each classroom. LPA Nunez reviewed the earthquake and fire drill logs and it’s noted that their last earthquake and fire drills were done in July 2023.

On 10/10/23 LPA Nunez interviewed 7 staff members including the director. The director Staff#1 (S1) stated that in the summer the facility conducted 2 disaster drills in July and August and prior to that they would do it every 2 months. S1 stated S1 will go down the hallway and ring a bell to signal the drills. S1 stated their emergency exits are the front exit door that leads to the parking lot and the back exit door that leads to the outside playground. 6 out of 6 staff stated they knew where the emergency exits were located.

LPA reviewed the facility’s Disaster and Mass Casualty Plan: Fire drills were conducted on the months of Jan 17, 2023, February 16, 2023, May 18, 2023, and July 25, 2023, based on record review and earthquake drills were conducted on Jan 19, 2023, Feb 9, 2023, May 23, 2023, and July 20, 2023. 4 out 6 staff that were employed during the time the drills occurred stated they have not practiced a fire or earthquake drills during the time they have been working at the facility. One staff was not employed during the time the drills occurred.

On 11/07/23 LPA Nunez interviewed 5 children. 3 out 5 children knew what to do in a fire drill. 2 out 5 children knew what to do in an earthquake drill. 5 out 5 children do not know when there was a fire or earthquake drill done in the facility.

LPA Nunez contacted 5 parents and was able to interview 2 parents. All interviewed parents stated they did not have any concerns with the facility.


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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 06-CC-20231004154408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IRVINE MONTESSORI SCHOOL
FACILITY NUMBER: 304370495
VISIT DATE: 12/21/2023
NARRATIVE
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According to California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101174(d) Disaster and Mass Casualty Plan: Disaster drills shall be conducted at least every six months.

Based on staff interviews and record reviewed it has been determined that the facility has not conducted a disaster drill at least every six months and provided documentation of a fire and earthquake drill logs with dates and times that did not occur. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter 12, is being cited on the attached LIC 9099D for the deficiency Section 101174(d) Disaster and Mass Casualty Plan and Section 1596.855(c) H&S Conduct Inimical.



Exit interview conducted and report was reviewed with Director Ruby Cabrera. Notice of site visit was given and must remain posted for 30 days. Failure to comply with the posting requirements shall result in an immediate civil penalty of $100.

Appeal Rights were explained. The Director was provided with a copy of the 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.

End of Report

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 06-CC-20231004154408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: IRVINE MONTESSORI SCHOOL
FACILITY NUMBER: 304370495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/10/2024
Section Cited
CCR
101174(d)
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101174(d) Disaster and Mass Casualty Plan...Disaster drills shall be conducted at least every six months and shall be documented.

This requirement is not met as evidenced by:
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The faiclity will conduct a disaster drill and documented and it will have the staff signatures and director will send a copy to LPA Nunez by the POC due date via email.
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Based on staff interviews and record reviews it has been determined that the facility has not conducted a disaster drill at least every six months.
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Deficiency Dismissed
Type B
01/10/2024
Section Cited
HSC
1596.855(c)
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1596.885(c)H&S- Conduct Inimical - conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.

This requirement is not met as evidenced by:
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The faiclity will conduct a disaster drill and documented and it will have the staff signatures and director will send a copy to LPA Nunez by the POC due date via email.
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Based on staff interviews and record reviews the facility provided a documentation of fire and earthquake drills with dates and times that did not occur.
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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: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4