304371487-8-5-2022-06-CC-DVAA-CGZN7Y-20220805101332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371487
Report Date: 08/05/2022
Date Signed: 08/05/2022 10:13:42 AM

Document Has Been Signed on 08/05/2022 10:13 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	GREAT FOUNDATIONS MONTESSORI-WOODBURY		FACILITY NUMBER:	304371487
ADMINISTRATOR:	KIMBROUGH, KARI		FACILITY TYPE:	850
ADDRESS:	6304 IRVINE BLVD.		TELEPHONE:	(714) 389-2400
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY: 199	TOTAL ENROLLED CHILDREN: 199	CENSUS: 109	DATE:	08/05/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kari Kimbrough, director		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Valencia conducted an on site inspection for the purpose of a Case Management Incident inspection, in response to an Unusual Incident Report submitted to the Licensing office on 7/27/22. LPA and the facility representative toured the facility inside and outside, and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 10 preschool children with 14 preschool staff. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. 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. An Unusual Incident Report UIR LIC624 form was submitted to the Licensing office on 7/27/22 detailing that a child #1(see Confidential Names List LIC811) was left in a classroom unsupervised. Two staff, staff #1 and staff #2 lined up a group of children to go outside, a child, child #1 remained in the classroom, and was later found by another staff #3. During today's inspection, LPA Valencia conducted a physical plant inspection of the facility, interviewed the director, and reviewed a video of the incident. In the video reviewed by LPA of the incident, LPA witnesses in class #7 that both staff #1 and staff #2 do a head count of the children when lining up to go outside. It is observed in the video that child #1 is at the back of the line and hides under a table. Staff did not see the child hiding under the table. When children and staff #1 and staff #2 arrived outside and did a 'name to face' roll call, staff #1 realized child #1 was not outside with the group, and came running indoors into the room #7. At the same time, it is observed in the video that a staff #3, the director discovers the child #1 in the classroom #7 unattended 90 seconds later. It was determined form the information available to LPA during the inspection, that the facility violated Title 22 Regulations Supervision 101229(a)(1). A printout of Title 22 Regulations Personal Rights was reviewed and provided for the director. Based on review of the video footage of the incident, LPA was able to make the determination that this child was not in any immediate danger, nor had an immediate threat to this or any children's health and safety. (continued on LIC809C)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

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: GREAT FOUNDATIONS MONTESSORI-WOODBURY	FACILITY NUMBER: 304371487
	VISIT DATE: 08/05/2022

NARRATIVE

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This incident did result in a potential threat to this child's health and safety and as a result the facility is therefore being cited a B violation. The facility reviewed name to face counting procedure with all staff the next day after the incident on 7/27, and proof of this training with staff was gathered by LPA. Facility was forthcoming of the incident and reported this incident timely.

Based on LPAs video review, and interview with the director the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22 Section 101229(a)(1) , is/are being cited on the attached LIC 809D.

Appeal Rights and deficiencies were 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. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2022 10:13 AM - It Cannot Be Edited

Created By: Dean Valencia On 08/05/2022 at 10:00 AM

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: GREAT FOUNDATIONS MONTESSORI-WOODBURY	FACILITY NUMBER: 304371487
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/12/2022 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. The above was not met as evidenced by: Based on review of video of an incident,	1 2 3 4 5 6 7	The facility reported the incident to Licensing office within 24 hours, and has trained all preschool staff on conducted name to face procedure both indoors and outdoors when transitioning. Additional attention is being payed to child #1, most notably when transitioning and possibilities of hiding from staff at that time. Proof of this correction was
	8 9 10 11 12 13 14	LPA determined that a child #1 was in a classroom #7 unsupervised for 90 seconds. This is a potential threat to the children's health and safety.	8 9 10 11 12 13 14	gathered at the time of today's inspection on 8/5/22.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Judy Hanson

LICENSING EVALUATOR NAME:

Dean Valencia

LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC809 (FAS) - (06/04)

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