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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304371246
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:41:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/25/2024 and conducted by Evaluator Dianna ValdezSantana
COMPLAINT CONTROL NUMBER: 06-CC-20240325092411
FACILITY NAME:MARCO POLO CHILDREN'S SCHOOLFACILITY NUMBER:
304371246
ADMINISTRATOR:GERMAIN, STACYFACILITY TYPE:
850
ADDRESS:17861 VON KARMAN AVENUETELEPHONE:
(949) 333-5388
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY:168CENSUS: 79DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Director, Kimberly GarciaTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are not properly trained.
Staff does not ensure disaster drills are being conducted.
Director falsely documented CCL documents.
INVESTIGATION FINDINGS:
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On 06/20/2024 Licensing Program Analyst (LPA) Dianna Valdez Santana made an unannounced visit to Marco Polo Children’s School for the purpose to deliver findings of a complaint received. Upon arrival, LPA was met by Director, Kimberly Garcia. Director was explained the reason for today’s visit. LPA was provided a tour of the facility and census was taken in individual classrooms; LPA observed 23 Staff caring for 79 children present at the time of inspection.

A review of the Facility Personnel Report Summary conducted on today’s date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
On 03/25/2024 a complaint was filed with the Licensing office stating, Staff are not properly trained, Staff does not ensure disaster drills are being conducted and Director falsely documented CCL documents. Reporting Party (RP) stated, “no disaster drills are being conducted at the facility. Staff are not aware of what the facility disaster plan is, because the director does not go over the plan with staff. Page 1 of 4
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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 6
Control Number 06-CC-20240325092411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MARCO POLO CHILDREN'S SCHOOL
FACILITY NUMBER: 304371246
VISIT DATE: 06/20/2024
NARRATIVE
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Staff #1 (S1) told staff that drill cannot be conducted with other staff and day care children. RP states, S1, has falsely documented that the facility did a drill back in December 2023.”

During the course of investigation, LPA interviewed 8 staff members, and 5 parents and 5 children were interviewed.

During the staff interviews, Staff 2 (S2), disclosed that the facility just had one (disaster drill) last week, earthquake and fire. Prior to that, we had not had one since I started here. S1was telling staff to do it on their own, but they didn’t. S2 said the staff did not conduct an emergency drill in December 2023. S2 said they tried to inform staff about the emergency plan, but the staff were lost. S2 does not feel the facility has trained staff and credits S2’s training from previous employment. The facility has 3 trainings a year, but they are very repetitive. S2 is not sure if the previous Director falsified documents but said if the former Director says the staff have done drills staff have not.

Staff 3 (S3) said the staff haven’t done disaster drills in a while; the staff just did one 2-3 weeks ago. S3 said the facility did not conduct a drill in December 2023. The last time S3 can remember maybe the first year in 2021. S3 said as of 3 weeks ago S3 now knows the school’s emergency plan but before that a little not too much. S3 said S3 doesn’t know if the Log was falsified because staff don’t have access to the log but the staff for sure did not do a disaster drill in December 2023. S3 said S3 would like to be more trained, like when S3 started, S3 would have liked more training. More training on Reggiano Schools, their philosophy.

Staff 4 (S4) disclosed, staff did the fire and earthquake drill this month. Before May, the staff did but S4 cannot remember when. S4 could not remember if a disaster drill was conducted in December 2023. S4 said S4 knows the emergency plan because it was just conducted yesterday. Staff get training about 2 times a year and feels sufficiently trained. Staff 5 (S5) stated Recently they have been trying to do disaster drills once a month. Prior to that once a year or maybe twice. That sounds familiar, S5 remembers having a drill at the end of the year (2023). S5 stated in regard to the school’s emergency plan, prior to yesterday S5 had an idea for the fire drills not for any other emergencies. Staff get trained about 3-4 times a year, S5 now feels sufficiently trained but did not before. S5 does not know if Disaster drill documents were falsified.

Staff 6 (S6) could not remember if staff conducted a drill in December of 2023. S6 said S6 is aware of the school’s emergency plan; staff did it individually but now all staff are doing it collectively. S6 does not know if the Drill log is false. Page 2 of 4

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 06-CC-20240325092411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MARCO POLO CHILDREN'S SCHOOL
FACILITY NUMBER: 304371246
VISIT DATE: 06/20/2024
NARRATIVE
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Staff get training 2-3 times a year and feels sufficiently trained. Staff 7 (S7) disclosed that they just started conducting emergency drills this year and was not aware of any drill conducted in December 2023. S7 said S7 is now aware of the school’s emergency plan but when the previous Director was here S7 was not really aware of the plan. S7 said staff get trained about 3 times a year, there are staff development days but feels insufficiently trained. S7 disclosed as far as S7 knows only the Disaster Drill was falsified by the former Director. S7 said S7 and Staff 8 (S8) would try to tell S1 that staff needed to do it but S1 said individually they should do it. But S8 and S7 tried to tell S1 that staff should do it all together, but S1 said no, S7 and S8 even offered to take it on, but S1 still said no. Staff 8 (S8) stated Staff did a fire and earthquake drill last week and prior to that probably not for up to 3 years and is not aware of any drill conducted in December of 2023. S8 said when previous Director was present S8 was not aware of the school’s emergency plan but after S1 left, S8 now knows the emergency plan. There are trainings for staff about twice a year and admits S8 still does not feel sufficiently trained. In addition, thinks there is not enough training for new staff. S8 disclosed that S1 lied about conducting the drills. S1 would say for classes to do them individually but would not follow up to see if they did or not. For over the 3 years staff constantly tried to convince S1 and offered to conduct the drills, but S1 did not want to and would say no.

5 of 8 parents were interviewed, 5 of 5 parents interviewed had no issues or concerns with the daycare.



5 out 5 children interviewed. 3 out of 5 children stated they remember emergency drills being done but there were inconsistencies in how many were conducted.

LPA obtained 3 years (2021-2024) of Emergency Drill logs, logs showed previous director had documented the facility had been conducting drills every 3 months but 6 out of 8 staff denied conducting drills in December 2023 or at all for the last few years. 5 out of 8 staff stated they do not feel sufficiently trained. 5 out of 8 staff stated the facility had not previously been conducting emergency drills. 3 out of 8 staff stated the believe the previous Director falsified the Emergency Drill log. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101174(d)(2) Disaster and Mass Casualty Plan, CCR 101216(e)Personnel Requirements, and H&S1596.885(c) Conduct Inimical, 3 Type Bs are being cited on the attached LIC 809D. Please refer to attached 809D for documentation of deficiencies.
Page 3 of 4
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 06-CC-20240325092411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MARCO POLO CHILDREN'S SCHOOL
FACILITY NUMBER: 304371246
VISIT DATE: 06/20/2024
NARRATIVE
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Exit interview was conducted. The Notice of Site Visit was posted. Appeal Rights was explained. A copy of appeal rights (LIC 9058 1/16) was provided and their signatures on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.


Page 4 of 4. End of Report.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 06-CC-20240325092411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MARCO POLO CHILDREN'S SCHOOL
FACILITY NUMBER: 304371246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
CCR
101216(e)
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Personnel Requirements: All personnel shall be given on-the-job training... Such training or experience shall be appropriate to the job assigned and shall be evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
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Director, Kimberly Garcia will email LPA Valdez Santana @ dianna.valdezsantana@dss.ca.gov by POC due date. Director will send staff training agenda and staff sign in sheet. New Director held a staff training on 5/31/24.
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Based on LPA’s interviews, 5 out of 8 staff stated they do not feel sufficiently trained especially when it came to the facility’s emergency plan.
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Director stated they are creating a New Employee Binder that will cover Reggiano philosophy, classroom management, curriculum, policies, regulations etc..
Type B
07/20/2024
Section Cited
CCR
101174(d)(2)
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Disaster and Mass Casualty Plan
Disaster drills shall be conducted at least every six months. (2)The drills shall be documented…

This requirement is not met as evidenced by:
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Director, Kimberly Garcia will email LPA Valdez Santana the dtaff training agenda and staff sign in sheet. New Director held a staff training on 5/31/24 and went over facility Disaster Plan.
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Based on LPA’s interviews, 6 out of 8 staff disclosed that the facility did not conduct disaster drills in December 2023 or in the last 3 years. 5 out of 8 staff stated they do not feel sufficiently trained especially when it came to the facility’s emergency plan.
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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: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 06-CC-20240325092411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MARCO POLO CHILDREN'S SCHOOL
FACILITY NUMBER: 304371246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
HSC
1596.885(c)
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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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Per the New Director,The owner of the facility terminated the previous Director and hired New Director The new Director stated the facility is currently conducting drills every month. Director created a "Licensing Requirements" audit document that the 3 admin must do individually on a monthly
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Based on LPA’s interviews, 3 out of 8 staff disclosed that the previous Director falsified the emergency drill log.
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basis to ensure the facility is in compliance. Director will email LPA "Licensing Requirements" audit document.
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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: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6