304371442-4-17-2024-06-CC-AFCN-D4EQRQ-20240417122420

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371442
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:24:34 PM

Document Has Been Signed on 04/17/2024 12:24 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:	ACACIA MONTESSORI SCHOOL		FACILITY NUMBER:	304371442
ADMINISTRATOR:	CHUNG, SUN		FACILITY TYPE:	830
ADDRESS:	1701 EAST CHAPMAN AVENUE		TELEPHONE:	(336) 870-2176
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	13	CENSUS: 8	DATE:	04/17/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director Sun Chung		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/17/24 at 9:00am, Licensing Program Analyst (LPA), Anna Chan conducted an unannounced onsite inspection for the purpose required Annual Random visit. LPA met with Director Sun Chung. Director and LPA toured the facility inside and outside and the floor and yard plan were verified. Census was taken, the overall census observed was 8 infants and 4 staff in the Infant Room. Infants are doing free play when LPA arrived. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:00a.m.- 6:00p.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. During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Age-appropriate materials are provided. LPA observed the Infant changing table is not within arm’s reach of a sink. Formulas are brought from home. Food prep areas were clean and sanitary. Food is properly stored. The Kitchen area is separate from the infant room. The facility provides snack and lunch to children. Menus are posted where it can be seen by parents. Allergy list of children are also posted in the classroom, kitchen and in brightwheel app. Water is provided by a filtered water and sippy cups with children’s name on it. Page 1 of 4

SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

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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Document Has Been Signed on 04/17/2024 12:24 PM - It Cannot Be Edited

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: ACACIA MONTESSORI SCHOOL	FACILITY NUMBER: 304371442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101439(h)(4)

Infant Care Center Fixtures, Furniture, Equipment and Supplies

(h) Infant changing tables shall: (4) While in use, be placed within arm's reach of a sink. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above, the changing table is not within arm's reach of a sink which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Director stated she will to move the changing table within arm's reach to the sink. The director stated, the sink in the infant room is not a food prep area Director will provide photos of the changing table to LPA by due date of 5/17/24

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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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: ACACIA MONTESSORI SCHOOL	FACILITY NUMBER: 304371442
	VISIT DATE: 04/17/2024

NARRATIVE

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Infants nap on cribs. Beddings are brought home weekly for washing. The facility conducted an emergency drill on October 19, 2023. There is a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material used is turf grass and appeared to be enough to absorb falls. There is age-appropriate equipment in the play yard. Drinking water in the outdoor activity space is provided by sippy cups with the child’s name on it. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

4 Staff files were reviewed for staff present during the facility inspection on this date. Health screening and immunization as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 (a)(1) 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.
Proof of immunization against pertussis, measles for the facility were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporter training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires January 2026.

5 Children's records were reviewed, and there was a separate, complete, and current record for each child. In the areas reviewed, infant files do have LIC9227 or Individual Infant Sleeping Plan. There is also a complete record of the 15-minute Infant safe sleep log of the 5 records reviewed during today’s inspection, which is found to be within compliance. Sign in/out procedure was reviewed in Bright Wheel and found within for compliance. Each child representative has their own sign in ID for drop-ff and pick up.

During infant file review, LPA discovered that 4 of 5 children's files does not contain signed LIC9224 dated 05/03/2023 and 05/18/2023.

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SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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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: ACACIA MONTESSORI SCHOOL	FACILITY NUMBER: 304371442
	VISIT DATE: 04/17/2024

NARRATIVE

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CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES:
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 5-years after the date of the first test.

The facility has done Lead Test on December 20, 2022.

Currently, there are medications in the facility. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Transfer Request (LIC9182). The Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov and may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the Director
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

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SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: ACACIA MONTESSORI SCHOOL	FACILITY NUMBER: 304371442
	VISIT DATE: 04/17/2024

NARRATIVE

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NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Based on LPA observations, interview and records reviewed, the following violation were observed, in accordance with California Code of Regulations, Title 22, Division 12, Section 101439(h)(4) Infant Care Center Fixtures, Furniture, Equipment and Supplies are Health and Safety Code 1596.8595(c)(3) are being cited on the attached LIC 809D.

An Inspection and exit interview were completed with Director Sun Chung. The report was reviewed and discussed. Appeal Rights and deficiency was 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.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

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SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 04/17/2024 12:24 PM - It Cannot Be Edited

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: ACACIA MONTESSORI SCHOOL	FACILITY NUMBER: 304371442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8595(c)(3)

1596.8595 (c)(3) The licensee shall require each recipient of the licensing report described in paragraph (1) pertaining to a complaint investigation to sign a statement indicating that he or she has received the document and the date it was received. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above 4 of 5 children's file do not have signed acknowledgement receipt of LIC9224 dated 05/03/2023 and 05/18/2023 and licensing report LIC9099 to all infant families by the next business day. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	Director stated she will have the parent's sign and acknowledge the LIC9224 the next business day and will provide a copy to LPA by due date of 4/24/24

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC809 (FAS) - (06/04)

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