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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371487
Report Date: 06/25/2024
Date Signed: 06/25/2024 02:20:01 PM

Document Has Been Signed on 06/25/2024 02:20 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GREAT FOUNDATIONS MONTESSORI-WOODBURYFACILITY NUMBER:
304371487
ADMINISTRATOR/
DIRECTOR:		KIMBROUGH, KARIFACILITY TYPE:
850
ADDRESS:6304 IRVINE BLVD.TELEPHONE:
(714) 389-2400
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 199TOTAL ENROLLED CHILDREN: 199CENSUS: 112DATE:
06/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Kari Kimbrough, Director TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 06/25/2024, Licensing Program Analyst (LPA) Tran and Jung conducted a case manager
to deliver finding for the above complaint allegation. LPA Tran met with Director Kari Kimbrough. A tour of the facility was conducted, and census was taken. Observed at the time of the visit was a total of 112 preschool children and 14 staff members in 8 classrooms.

A review of the Facility Personnel Report Summary on 06/25/2024 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 04/25/2024, the Regional Office received an unusual incident report (UIR) to report an incident in which Child #1 (C1) sustained injury at the facility on 03/11/2024. According to the Director, the incident occurred on the date the Director was absent from facility. Staff who involved in the incident took appropriate steps to provide first aid for child, call parent and complete ouch report for child's parent. However, staff members did not inform the Director to follow up with the incident. C1 was later on reported to receive medical treatment at the hospital. Due to not being informed about the incident, Director did not submit an UIR to Community Care Licensing to report the injury/incident occurred on 03/11/2024. Director stated she submitted the UIR on 04/25/2024, due to a concern being brought up by child's representative related to the incident occurred on 03/11/2024.
According to Title 22, Division 12, Chapter 1 Section 101212 Reporting Requirements (d) Upon the occurrences, during the operation of the child care center of any of the events, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (B) Any injury to any child that requires medical treatment. Based on LPA interview and record review, the facility was found to be out of compliance with this requirement. Deficiency was observed and cited on the attached LIC809D. (Continue next page)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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 3
Document Has Been Signed on 06/25/2024 02:20 PM - It Cannot Be Edited


Created By: Nguyen K Tran On 06/25/2024 at 11:55 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: 06/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
CCR
101212(d)(1)(B)

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101212 Reporting Requirements (d)... a written report shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include...(B) Any injury to any child that requires medical treatment. This requirement is not met evidenced by:
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Director will submit a detailed plan to ensure all incidents are being reported according to Title 22 Reporting Requirements, to LPA, by due date.
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Based on interview and record review, Director confirmed that due to miscommunication, an incident which occurred on 03/11/2024 was not reported to CCL until 04/25/2024, this posed a potential health, safety and personal rights risk to the 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:Martha Malane
LICENSING EVALUATOR NAME:Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024


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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GREAT FOUNDATIONS MONTESSORI-WOODBURY
FACILITY NUMBER: 304371487
VISIT DATE: 06/25/2024
NARRATIVE
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(Page 2 of Report)

Appeal Rights and deficiency 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 Director Kari Kimbrough.

(End of Report)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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