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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371442
Report Date: 05/23/2024
Date Signed: 05/23/2024 09:09:22 AM


Document Has Been Signed on 05/23/2024 09:09 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:ACACIA MONTESSORI SCHOOLFACILITY NUMBER:
304371442
ADMINISTRATOR:CHUNG, SUNFACILITY TYPE:
830
ADDRESS:1701 EAST CHAPMAN AVENUETELEPHONE:
(336) 870-2176
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:13CENSUS: 10DATE:
05/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Director Stella ChungTIME COMPLETED:
09:25 AM
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On 5/23/24 at 8:35am, Licensing Program Analyst (LPA) Anna Chan conducted a Plan of Correction (POC) inspection in response to a Type B violation issued on 04/17/24, 101439(h)(4) Infant Care Center Fixtures, Furniture, Equipment and Supplies, were changing table was not within arm’s reach of a sink in the infant room.

LPA met with Director Stella Chung. Current census observed was 10 infants and 3 staff.

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

The area cited was re-inspected and found to be corrected. Changing table was within arm’s reach of a sink. Deficiency cleared.

No further action needed at this time. POC letter given, and correction have been received at this time.

Exit interview conducted and report was reviewed with the Director Stella Chung. 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 were explained. The director was provided a copy of 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

SUPERVISOR'S NAME: Martha MalaneTELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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