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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371430
Report Date: 10/30/2023
Date Signed: 10/31/2023 08:48:41 AM

Document Has Been Signed on 10/31/2023 08:48 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MONTESSORI OF LAGUNA NIGUELFACILITY NUMBER:
304371430
ADMINISTRATOR:PULIYANDA, ANNAFACILITY TYPE:
850
ADDRESS:31171 NIGUEL ROADTELEPHONE:
(949) 661-5437
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 20DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Anna PuliyandaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite inspection for the purpose of an Annual Required inspection. LPA met with director, Arunal (Anna) Pullyanda at the time of arrival. LPA toured the facility inside and outside with the director. The floor and yard plan (LIC 999) were checked. LPA took census, there were a total of 20 preschool children present with 3 staff in two rooms. LPA inspected three classrooms (1, 2, and 3). More staff and more children arrived during LPA's inspection. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:00 a.m.- 6:00 p.m., Monday through Friday. 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 except for staff, Shuying (Loria) Cai who has been at the facility since July 2023. This violation was cited and immediate civil penalty of $500.00 was assessed.
During the inspection of the indoor activity space, items which could pose a danger to children (cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Parents provide morning, and lunch to children. Facility provides afternoon snack to children. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. Drinking water is available to children indoors by water bottles that children bring from home and the facility fill them out by a filtered water dispenser if needed.
Children nap on cots, and bedding is stored individually and washed on a weekly basis. The facility has conducted an emergency drill within the past six months, last drill was in 6/21/2023.
The facility does not have a working carbon monoxide detector. Facility met all posting requirement.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430
VISIT DATE: 10/30/2023
NARRATIVE
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The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. There are two exit gates leading to parking lot which was equipped with additional latch on the top. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material foam cushioning and synthetic grass commercially produced for the purpose around the climbing equipment, slides and other similar equipment appeared to be enough to absorb falls. Drinking water in the outdoor activity space is provided by water containers children brought from home and the facility fills them out by filtered water dispenser if needed. There is also drinking fountain available to children. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility.
Staff files were reviewed for staff present during the facility inspection on this date, 4 staff files were reviewed. Health screening and immunization as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and not in compliance.(one staff missing the requirement). Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years.(One staff missing the requirement). At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 06/2025.
Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 5 children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance except for 5 children missing LIC 613A on file. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. This procedure is electronically.
Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care
Centers (CCCs) constructed before January 1, 2010, to test their water (used for
drinking and food preparation) for lead contamination before January 1, 2023, and then every
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430
VISIT DATE: 10/30/2023
NARRATIVE
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5-years after the date of the first test. LPA verified that the lead testing was not completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. Facility did not complete testing prior to their deadline of 1/1/2023. LPA referred the director, Anna Pullyanda to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301(voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at:https://www.ada.gov/resources/child-carecenters

The director, Anna Pullyanda was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communications.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430
VISIT DATE: 10/30/2023
NARRATIVE
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The director, Anna Pullyanda was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the


email address provided. Please complete the survey and share your inspection experience. If
you have any questions regarding the process or CARE tools, please send email inquiries to
inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its
tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given to director, Anna Pullyanda and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

In the areas that were evaluated, the following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.


Type A HSC 1596.871(c)(1)(A), Type B HSC 1597.16(a)(1) and HSC 1596.7995(a)(1), HSC 1596.954, HSC 1596.8662(b)(1), and CCR Section 1012116(f) and 101223(b)(1).
LPA Malek informed director, Anna Pullyanda that this report dated 10/30/2023 document one type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Malek informed the director, Anna Pullyanda to provide a copy of this licensing report dated 10/30/2023 that documents any Type A citation 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.

Exit interview conducted and report was reviewed with the director, Anna Pullyanda

End of report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2023 08:48 AM - It Cannot Be Edited


Created By: Mahnaz Malek On 10/30/2023 at 11:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one person which poses an immediate health, safety or personal rights risk to persons in care. Staff, Shuying (Loria) Cai who was supervising children at the time of arrival at 8:15 am, did not have proof of her clearance ID number being transferred to the facility. She has been working at the facility since July 2023. Immediate civil penalty of $500.00 was assessed.
POC Due Date: 10/31/2023
Plan of Correction
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The director stated she went ahead and filled out the required form and emailed the form to the office to transfer staff's clearance to this facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


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Document Has Been Signed on 10/31/2023 08:48 AM - It Cannot Be Edited


Created By: Mahnaz Malek On 10/30/2023 at 11:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the facility which poses a potential health, safety or personal rights risk to persons in care. LPA did not observe any carbon monoxide in the facility. The director stated it was mounted on the hallway and must have been removed during paint job recently.
POC Due Date: 11/02/2023
Plan of Correction
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The director agreed to have this device mounted on the wall. It was arranged that the device was delivered to the facility during LPA's inspection.
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in the whole facility which poses a potential health, safety or personal rights risk to persons in care. The facility did not comply with water testing for lead before the due date of 1/1/2023.
POC Due Date: 11/30/2023
Plan of Correction
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The director agreed to comply with this section and send the proof of testing to LPA's email address before the due date of 11/30/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


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Document Has Been Signed on 10/31/2023 08:48 AM - It Cannot Be Edited


Created By: Mahnaz Malek On 10/30/2023 at 11:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of four files which poses a potential health, safety or personal rights risk to persons in care. Staff # 3 did not have proof of mandated reporter training certificate on file.
POC Due Date: 11/06/2023
Plan of Correction
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4
The director stated she would send a copy of staff # 3's certificate to our office before the due date of 11/6/2023.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of four files which poses a potential health, safety or personal rights risk to persons in care. Staff # 3 did not have proof of MMR, Dtap Vaccine on file.
POC Due Date: 11/06/2023
Plan of Correction
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4
The director stated she would send a copy of staff # 3's MMR and Dtap vaccines to our office before the due date of 11/6/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 10/31/2023 08:48 AM - It Cannot Be Edited


Created By: Mahnaz Malek On 10/30/2023 at 11:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of 4 files which poses a potential health, safety or personal rights risk to persons in care. There was one staff present with current CPR and 1st aid. There is no other staff wit current CPR and 1st aid to cover the whole hours of operation.
POC Due Date: 11/14/2023
Plan of Correction
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2
3
4
The director stated she would sign up more staff for this certificate. She made an appointment for this training 11/3/2023.
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in five out of five files which poses a potential health, safety or personal rights risk to persons in care. Five children did not have the personal rights form LIC 613A signed by parents on their files.
POC Due Date: 11/06/2023
Plan of Correction
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2
3
4
The director stated she would have the parents complete the forms and send the verifications to our office by the due date of 11/6/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


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