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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371475
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:44:52 PM


Document Has Been Signed on 04/06/2023 03:44 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:BUENA PARK MONTESSORI ACADEMYFACILITY NUMBER:
304371475
ADMINISTRATOR:SAVITHRI DE ALWISFACILITY TYPE:
830
ADDRESS:6221 LINCOLN AVENUETELEPHONE:
(714) 821-7800
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:27CENSUS: 20DATE:
04/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Vivian Neino, Director TIME COMPLETED:
04:00 PM
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On 04/06/2023 Licensing Program Analyst (LPA), Stella Gutierrez made an unannounced visit to the facility for the purpose of plan of correction verification and to clear deficiencies that were previously cited on 03/29/2023. LPA was met by Harshi Gunasekara, assistant director and Vivian Neino, director who was explained the reason for today’s visit. Census taken today, LPA observed 02 infant staff and 08 infants in the infant room and 02 toddler option staff preschool staff and 12 toddler children in care.

A review of the Facility Personnel Report Summary conducted on 04/06/2023 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.



On 03/29/2023 a visit was made to the facility for a case management inspection to cite deficiencies observed via video footage of the days of 01/06/2023 and 01/23/2023.

On 04/05/2023 LPA, Gutierrez received the proof of corrections agreed from the director Vivian Neino via email. During today's inspection the director was advised the remaining 6 Type A deficiencies will be cleared today. LPA observed the full report and notice of site visit posted at the entrance of the facility.

LPA conducted an interview with assistant director , obtained a copy of the toddler option daily schedule, the personnel report and the children's roster.


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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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: BUENA PARK MONTESSORI ACADEMY
FACILITY NUMBER: 304371475
VISIT DATE: 04/06/2023
NARRATIVE
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On 03/29/2023 it was indicated on the report stating: That reports dated 03/29/2023 documents 07 Type A citations. Type A citations which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care. Also, LPAs Stella Gutierrez and Achibaldo Silva informed the director to provide a copy of this licensing report dated 03/29/2023 that documents any Type A citations 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 did not observe 11 forms signed and placed Iin the children's files out of the 20 children's files reviewed and present today.

Based on today's observation the following deficiency was revealed during today's visit and is being cited in accordance to Health and Safety Codes 1596.8595 (3)(4).

Exit interview conducted with the director, Vivian Neino, appeal/applicant right and notice of site visit was provided.

LPAs Stella Gutierrez informed director, Vivian Neino that this report dated 04/06/2023 documents 01 Type A citations. Type A citations which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care. Also, LPAs Stella Gutierrez informed the director to provide a copy of this licensing report dated 04/06/2023 that documents any Type A citations 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.

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.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/06/2023 03:44 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: BUENA PARK MONTESSORI ACADEMY
FACILITY NUMBER: 304371475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2023
Section Cited

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1596.8595 reports to be provided to parents or guardian of each child receiving services (3) The licensee shall require each recipient of the licensing document pertaining to a conference to sign a statement indicating that he or she has received the document and the date it was received.
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The director agrees to have the authorized representatives sign and place form LIC 9224 in the files for reports dated 03/29/2023 C3, C4, C6, C8, C12, C13, C15, C17, C18, C19 and C20 by the next business day or the next time the child is present at the facility.
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(4) The licensee shall keep verification of receipt in each child's file.

This requirement was not met as evidence by records review that 11/20 children present today did not have a LIC 9224 signed and placed in files. This poses a potential risk to the children 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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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