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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304371039
Report Date: 05/03/2023
Date Signed: 05/03/2023 03:05:49 PM

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
04/26/2023 and conducted by Evaluator Dean Thompson
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20230426094942
FACILITY NAME:BELLA MONTESSORIFACILITY NUMBER:
304371039
ADMINISTRATOR:EVANGELISTA, STEFANIEANFACILITY TYPE:
850
ADDRESS:20602 PRISM PLACETELEPHONE:
(949) 900-2420
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:150CENSUS: 129DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Stefanie EvangelistaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not follow proper emergency procedures
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Thompson conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 4/28/2023. Upon arrival LPA met with Director Stefanie Evangelista to deliver complaint findings. Stefanie Evangelista guided LPA on a tour of the facility. LPA observed a total of 129 Preschool age children with 23 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 the visit, it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios.

On 4/26/2023 a complaint was received alleging Staff did not follow proper emergency procedures.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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-20230426094942
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: BELLA MONTESSORI
FACILITY NUMBER: 304371039
VISIT DATE: 05/03/2023
NARRATIVE
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During the course of the investigation, LPA interviewed Director, interviewed staff, reviewed child (C1) file, and obtained the facility roster.

During staff interviews on 4/28/2023, LPA interviewed staff that had direct knowledge of the incident involving (C1). During staff interviews and reviewing a self-reported incident report dated 4/24/2023, it was determined (C1) was playing in the indoor play yard when (C1) tripped, fell, and hitting their head on the concrete floor. All staff interviewed stated (C1) was lying on the ground, unresponsive. One staff interviewed recalled asking another staff to call for help or the front office. The front office was notified, and a staff member came to the inside play area where the incident occurred. The staff member was returning to the office to call (C1) parents and observed the parent of (C1) inside the facility which the parent was then notified of the incident.

Child (C1) was escorted out of the facility by the parent. Parent and (C1) returned inside the facility minutes later and requested the facility to call 911. Facility called 911 per parent request.

Based on documents received, LPA interviews with Director and staff, 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 9099 D for the deficiency section 101226 Health-Related Services.

LPA Thompson informed Director Stefanie Evangelista that this report dated 5/3/2023 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Thompson informed Director Stefanie Evangelista to provide a copy of this licensing report dated 5/3/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 06-CC-20230426094942
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: BELLA MONTESSORI
FACILITY NUMBER: 304371039
VISIT DATE: 05/03/2023
NARRATIVE
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Exit interview conducted and report was reviewed with the Director Stefanie Evangelista. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 06-CC-20230426094942
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: BELLA MONTESSORI
FACILITY NUMBER: 304371039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/10/2023
Section Cited
CCR
101226(c)
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101226 Health-Related Services (c) The licensee shall obtain emergency medical treatment without specific instructions from the child's authorized representative if the authorized representative cannot be reached immediately, or if the nature of the child's illness or injury is such that there should be no delay in getting medical treatment for the child. This requirement was not met as evidenced by:
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Director stated they will develop and implement a written plan for when a child has encountered a head injury and submit the written plan to LPA by POC due date.
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Based on interviews conducted it was determined that (C1) was unresponsive due to hitting their head on the concrete floor. The facility did not call 911 until the parent requested the facility to do so.
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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: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
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