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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371464
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:42:22 PM

Document Has Been Signed on 12/06/2023 04:42 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SMILES MONTESSORI CHILDCAREFACILITY NUMBER:
304371464
ADMINISTRATOR:AHN, SUNG JAFACILITY TYPE:
850
ADDRESS:2261 NORTH ORANGE OLIVE ROADTELEPHONE:
(714) 283-2857
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 12DATE:
12/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Director, Sung Ja AhnTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing program analysts (LPA) Valdez Santana and Jung conducted a case management visit due to deficiencies observed during complaint investigation visit on 12/06/2023. On 12/06/2023, LPAs arrived at the facility and were met by Director, Sung Ja Ahn (aka Ms. Annie). Director provided LPAs a tour of the facility. During the inspection, LPAs observed 1 preschool staff member providing care for 12 preschool children.

A review of staff records on this date indicated that not all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs discovered that individual, Nicole Lockmer has background clearance but has not been associated to the facility. Nicole Lockmer stated she has been employed at the facility since May of 2023. Director stated that she gave the staff the form but upon file review and then forgot to call the Licensing office to get N. Lockmer associated. LPAs observed the form given to the staff was an incorrect form. The correct form was submitted to the Licensing Office before the end of the visit.

Based on LPAs’ observations, 6 out of 6 staff had incomplete files. Five random children’s files were reviewed, 5 out of 5 children had incomplete files.



Therefore, in the areas that were inspected, one Type A deficiency was observed of the California Code of Regulations, Title 22, Division 12 Section 101170(e)(2) Criminal Record Clearance for failing to associate Nicole Lockmer prior to working at the facility and two Type B CCR 101217(a) Personnel Records and CCR 101221(a) Child’s Records for incomplete staff and children’s files. See attached LIC809D.

LPAs informed facility representative, that this report dated 12/06/2023 documents 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. Page 1 of 2.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SMILES MONTESSORI CHILDCARE
FACILITY NUMBER: 304371464
VISIT DATE: 12/06/2023
NARRATIVE
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LPA Valdez Santana and Jung also informed the facility representative to provide a copy of this licensing report dated 12/06/2023, 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 was conducted. The Notice of Site Visit must be posted for no less than 30 consecutive days. 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 2 of 2. End of Report
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2023 04:42 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 12/06/2023 at 03:06 PM
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: SMILES MONTESSORI CHILDCARE
FACILITY NUMBER: 304371464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
101170(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by:
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LPA Valdez Santana and Jung explained to the Director the difference between the LIC9182 and the LIC9163. Director stated she forgot to call the Licensing Office to get Nicole Lockmer associated. The correct form was submitted to Licensing office during visit and Nicole is now associated to facility.
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Teacher Nicole Lockmer began employment at the facilty in May 2023 and has been present at the facility without being associated to the facility. In Nicole's file, there was an imcomplete Live Scan form and Nicole needed the LIC 9182- Clearance transfer request.
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Director will email LPA Valdez Santana her Plan of Correction via email at dianna.valdezsantana@dss.ca.gov by POC due date.

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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:Thuy Ho
LICENSING EVALUATOR NAME:Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/06/2023 04:42 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 12/06/2023 at 03:26 PM
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: SMILES MONTESSORI CHILDCARE
FACILITY NUMBER: 304371464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited
CCR
101217(a)

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101217 Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement was not met by:
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Director stated she will ensure that all the staff files are complete by the POC due date. Director will remove irrelevant forms and make sure all the forms are filled out completely.
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6 out of 6 staff did not have complete files.
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Type B
01/08/2024
Section Cited
CCR101221(a)

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101221(a) Child's Records: A separate, complete and current record for each child is maintained in the child care center.

This requirement was not met by: 5 out of 5 children's records were incomplete.
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The Director stated will review all the children's files and note what is missing from each one and have parents finish filling out the forms by the POC due date.

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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:Thuy Ho
LICENSING EVALUATOR NAME:Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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