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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371487
Report Date: 09/12/2023
Date Signed: 09/12/2023 04:20:37 PM

Document Has Been Signed on 09/12/2023 04:20 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GREAT FOUNDATIONS MONTESSORI-WOODBURYFACILITY NUMBER:
304371487
ADMINISTRATOR:KIMBROUGH, KARIFACILITY TYPE:
850
ADDRESS:6304 IRVINE BLVD.TELEPHONE:
(714) 389-2400
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 199TOTAL ENROLLED CHILDREN: 201CENSUS: 172DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:24 AM
MET WITH:KIMBROUGH, KARITIME COMPLETED:
05:00 PM
NARRATIVE
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On 09/12/2023 Licensing Program Analyst (LPA) A Bootorabi made an unannounced visit to the facility for a self reported incident that occurred on 06/08/2023. LPA, Bootorabi was met by the director Kari & Laure. The LPA explained the reason for today's visit.

The census on today’s visit was as follows:
Room 10: 22 children & 1 Teacher
Room 9: 23 children & 1 Teacher
Room 8: 23 children & 1 Teacher
Room 7: 24 children & 1 Teacher
Room 6: 17 children & 2 Teacher
Room 5: 23 Children & 1 Teacher
Room 4: 19 children & 1 Teacher
Room 3: 21 children & 1 Teacher

A review of the Facility Personnel Report Summary conducted on 09/12/2023 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to the initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GREAT FOUNDATIONS MONTESSORI-WOODBURY
FACILITY NUMBER: 304371487
VISIT DATE: 09/12/2023
NARRATIVE
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On 06/08/2023 the facility reported to Community Care Licensing (CCL) an Unusual Incident Report (UIR) LIC624. The facility reported that a child (C1) grabbed a plate from the teacher as she was preparing lunches for students. The plate C1 grabbed had food items to which C1 is allergic, C1 took a bite. Shortly after C1 had an allergic reaction. C1 received medication that was stored in the facility by Staff 7 (S7). The parents of C1 were contacted, C1 was picked up, taken to the hospital by their parents, and administered an EpiPen.

LPA Bootorabi conducted a case management visit on 06/12/2023 to investigate the self-report incident submitted to CCL on 06/08/2023. LPA interviewed 6 of 7 staff present at the facility and involved in the incident. It was determined that C1 did not grab food off a plate but was served the wrong food by S1, S2, and S3. At the time of the incident, a fully qualified teacher was present in the classroom. It was also determined that S1, S2, and S3 did not verify the child’s allergies prior to providing and serving C1 their meal. A consultation was provided to the director to amend their UIR report due to the misleading information provided on the first UIR submitted on 06/08/2023.

During the visit LPA attempted to interview C1 but could not qualify for C1 during the time of the visit.

On 6/12/2023 Community Care Licensing received an amended Unusual Incident Report (UIR)LIC624 from the center. The updated UIR stated that Staff #1 (S1) brought the wrong lunch into the classroom, Staff #2(S2) gave the wrong lunch to C1, and Staff #3 (S3) confirmed C1 was given the wrong lunch. C1 received medication that was stored in the facility by S7. The parents of C1 were contacted, C1 was picked up, taken to the hospital by their parents, and administered an EpiPen.

LPA Bootorabi interview the Parent of C1 (P1) on 07/05/2023, P1 stated the center was aware of C1’s allergies during the enrollment period, two types of medication were provided to the center, and the S7 was trained by C1’s parent(s) on administering both of the medications on 5/13/2023. P1 stated the child was taken to the primary doctor's office on the day of the occurrence and was administered an Epi-pen.


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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GREAT FOUNDATIONS MONTESSORI-WOODBURY
FACILITY NUMBER: 304371487
VISIT DATE: 09/12/2023
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Based on LPAs record review, staff interviews, and parent interviews LPA was able to determine that this C1 was in immediate danger and there was an immediate threat to their health and safety. The following violation was determined in accordance with the California Code of Regulations, Title 22 Section 101227(7)(B) and the center is being cited on the attached LIC 809D.

During LPA's tour of the facility it was observed that children were laying on their cots awake without additional activities. The director was reminded that all children shall be given an opportunity to nap or rest without distraction or disturbance from other activities at the center. No child shall be forced to stay awake or to stay in the napping area longer than the normal napping period. A teacher-child ratio of one teacher
supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio specified in Section 101216.3(a) are immediately available at the center.

The following violation was determined in accordance with the California Code of Regulations, Title 22 Section 101230 (b)(3) and 101230 (c) and the center is being cited on the attached LIC 809D.


An exit interview was conducted, and the report was reviewed with the director, Kari. Appeal Rights 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.

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.

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.

End of Report

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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Document Has Been Signed on 09/12/2023 04:20 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/12/2023 at 03:13 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: GREAT FOUNDATIONS MONTESSORI-WOODBURY
FACILITY NUMBER: 304371487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2023
Section Cited
CCR
101227(7)(B)

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101227(7) Modified diets prescribed by a child's physician as a medical necessity shall be provided.(B)A child shall not be served any food to which the child's record indicates he/she has an allergy.This requirement was not met by evidence of a child being served
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The director stated she retrained the kitchen staff to re-read and follow directions given to the facility by the parents regarding food restrictions and allergies. The director stated moving forward they have now implemented putting the main teacher assigned to the classroom be present during mealtimes.
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 food to which the child’s records indicate they are allergic. This poses an immediate health and safety risk to children in care.
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Type B
09/12/2023
Section Cited
CCR101230(b)(3)

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101230 Activities (b)All children shall be given an opportunity to nap or rest without distraction...(3) No child shall be forced to stay awake or to stay in the napping area longer than the normal napping period. This requirement was not met evidence by:
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The director stated that she will be giving children in RM10 (Kinder) the option to rest and relax as needed. Then for the other classroom, the director stated she will have enough staff to do quiet activities with other children.
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Based on LPA's observation during the visit conducted on 9/12/2023 it was observed that children were layin in their beds awake during the facilities "nap time". Children were not observed to have additional activities provided to them and were observed to be in their mat or redirected to their mat.
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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 Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023


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Document Has Been Signed on 09/12/2023 04:20 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 09/12/2023 at 03:20 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: GREAT FOUNDATIONS MONTESSORI-WOODBURY
FACILITY NUMBER: 304371487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2023
Section Cited
CCR
101230(c)

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101230 Activities(c) A teacher-child ratio of one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio specified in Section 101216.3(a) are immediately available at the center. This was not met by evidence of LPA observing...
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The director stated that she will be giving children in RM10 (Kinder) the option to rest and relax as needed. Then for the other classroom, the director stated she will have enough staff to do quiet activities with other children. The director stated she has enough staff to support classrooms.
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children laying in their cots awake during the facilities nap time. RM 10 had all children(C) awake and 1(S), Rm9 23 children(1 awake) 1(S): Rm8 23 C/6awake/1T: R724C/6awake/1S: R6 2S/17C/3awake R5: 23 Children/4awake/1T R4: 19C1T/3awake R3 21C/3awake 1 T
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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 Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023


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