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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371465
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:45:05 PM

Document Has Been Signed on 05/19/2023 04:45 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:
304371465
ADMINISTRATOR:AHN, SUNG JAFACILITY TYPE:
830
ADDRESS:2261 NORTH ORANGE OLIVE ROADTELEPHONE:
(714) 283-2857
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 9DATE:
05/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Director, Sung Ja AhnTIME COMPLETED:
05:00 PM
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Licensing program analyst (LPA) Dianna Valdez Santana conducted a case management visit due to deficiencies observed during complaint investigation visit on 05/19/2023. On 05/19/2023, LPA Valdez Santana arrived at the facility at 8:30am. LPA met with Director, Sung Ja Ahn. LPA Valdez Santana toured the facility. During the inspection, LPA Valdez Santana observed 2 staff members including the Director providing care for 9 infant children by 10:11am there were 12 infant children in care.

Based on LPA's observations, interview and record reviews, daily sign in sheet the facility was operating over capacity. The facility representative was advised of over-capacity violation and a correction needs to be made by today. Capacity compliance has to be maintained at all times for the safety of the children in care. LPA discussed with Director the Department’s Capacity Regulations for her reference as this is a repeat violation within the same year. Director stated she had 3 staff terminate their employment last week and that she was already in the process of hiring new teachers but had struggled to hire new teachers. Upon LPA’s arrival there were 9 infants present and by 9:30am another staff arrived. At approximately 11am there were 12 infants present. The facility is licensed to care for 20 infant children but did not have sufficient staff to properly care for the 12 infants in care. The facility is operating out of capacity. This poses an immediate risk to the safety of children in care. LPA reviewed 10 children’s files and 10/10 infants’ files did not contain the 15 minute Sleeping Log. 2 of 2 infants under 12 months of age did not have the Individual Sleeping Plan forms in their files.

Therefore, in the areas that were inspected, one Type A and two Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Deficiencies observed are California Code of Regulations Chapter 1, Section 101416.5(b) Staffing Ratio and Capacity is being cited on the attached LIC809D. A civil penalty of $250.00 is being issued today as this has been cited twice within the last 12 months.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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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: 304371465
VISIT DATE: 05/19/2023
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Facility is also not in compliance with Infant Safe Sleep Regulations, and is being cited California Code of Regulations, Title 22, Division 12, Chapter 1, Section 102425 (j)(2) and Section 102425(c) Infant Safe Sleep. See 809D.

LPA Valdez Santana informed facility representative, Sung Ja Ahn that this report dated 05/19/23 documents one Type A citation and two Type B citations which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

LPA Valdez Santana also informed the facility representative to provide a copy of this licensing report dated 05/19/23, 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. LPA provided Director with a Safe Sleep Consultation, and provided a 15 minute log template and LIC 9227 Individual Infant Sleeping Plan form.

Exit interview was conducted. The Notice of Site Visit was 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.



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

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/19/2023 04:45 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 05/19/2023 at 03:35 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: 304371465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2023
Section Cited
CCR
101416.5(b)

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Infant Safe Sleep 101416.5(b): There shall be a ratio of one teacher for every four infants in attendance.

This requirement is not met as evidenced by:
Based on LPA's observation the facility did not comply with the section cited
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The director stated that the facility had 2 staff unexpectedly not be able to show up for care today due to personal reasons. 3 staff ended their employment unexpectedly. The director stated that they will draft a plan to address the lack of compliance with infant to teacher ratio and the staffing issue.
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above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed 1 infant teacher, 1 Director supervising 9 infants. WIthin the 3 hours of the inspection one more staff arrived and 3 more infants. for a majority of the insepction.
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Proof of this and the plan will be emailed to LPA by 5/22/23. $250.00 Civil Penalty was assessed due to repeat violation.
Type B
05/22/2023
Section Cited
CCR102425(c)

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Infant Safe Sleep:

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

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LPA provided Director with a Safe Sleep Consultation and provided Director with a LIC9227 form. Director will send LPA completed and signed LIC9227 forms for the children under 12 months of age via email at: dianna.valdezsantana@dss.ca.gov
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This requirement is not met as evidenced by:

LPA reviewed 10 infant children's files and 2 of 2 infants under 12 months of age did not have an LIC 9227 Individual Sleeping Plan form.
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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: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/19/2023 04:45 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 05/19/2023 at 04:13 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: 304371465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2023
Section Cited
CCR
102425(j)(2)

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Infant Safe Sleep:

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
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LPA provided Director a Safe Sleep Consulation and a 15 minute log template, Staff will begin documenting the infants sleeping and will send LPA 2 weeks worth of sleep logs via email at dianna.valdezsantana@dss.ca.gov
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 10 out of 10 infants did not have a 15 minute sleeping log. Staff was not documenting their observations while they slept which poses a potential health, safety or personal rights risk to persons in care.
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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: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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