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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371685
Report Date: 05/15/2026
Date Signed: 05/15/2026 03:22:32 PM

Document Has Been Signed on 05/15/2026 03:22 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:MONTESSORI SCHOOL OF SAN CLEMENTEFACILITY NUMBER:
304371685
ADMINISTRATOR/
DIRECTOR:		GJERTSON, MICHELLEFACILITY TYPE:
860
ADDRESS:1141 PUERTA DEL SOLTELEPHONE:
(949) 276-4160
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 189TOTAL ENROLLED CHILDREN: 189CENSUS: 84DATE:
05/15/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Director, Michelle GjertsonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 05/15/2026 Licensing Program Analyst (LPA) K. Trinh conducted an unannounced Case Management inspection. Upon arrival LPA met with Director, Michelle Gjertsen. A tour of the facility was conducted, and census was taken and the total census at that time observed was 84 children and 19 staff members. The facility was operating with staff-child ratios and within licensed capacity. A review of the Facility Personnel Report Summary conducted on today’s date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 05/06/2026 a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported that on 05/06/2026, Staff 1 (S1) was supervising fourteen (14) preschool children in Room 7 during nap time. At approximately 12:40PM, Child 1 (C1) was jumping on their mat and hit their head on a shelf. The facility informed C1’s authorized representative of the incident and they were picked up.

During today’s visit, LPA conducted interviews and obtained pertinent documents to the investigation.

During interviews, S1 stated that they were alone with fourteen (14) children for approximately ten (10) minutes. As S1 was patting another child to sleep, C1 jumped on their bed and hit their head on the hinge of a cabinet. S1 added that there were approximately four (4) children awake at that time, including C1. C1 was walking around the classroom and jumping on their bed and the other three (3) children were laying down on their cots.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: MONTESSORI SCHOOL OF SAN CLEMENTE
FACILITY NUMBER: 304371685
VISIT DATE: 05/15/2026
NARRATIVE
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(Page 2)
Staff 3 (S3) was in Room 7 to assist S1 at approximately 11:50AM-12:15PM. When S3 left, they recalled seeing S1 assisting C1 to lay down for nap time. There were no other staff members present when S3 left Room 7. S3 stated that C1 bumped their head on the cabinet while they were on break.

During record review, LPA obtained the incident report, staff time cards, and the daily attendance sheet from 05/06/2026. The incident report confirms that C1 had bumped their head on the cabinet, and their authorized representative was notified at 12:44PM. The attendance sheet confirms that there were fourteen (14) children present in Room 7. The employee time cards show that S1 was working from 8:25AM-1:08PM while Staff 4 (S4), S1's co-teacher in Room 7, was on break from 11:52AM-12:56PM.

Based on staff interviews and record reviews, the facility was not in compliance with California Code of Regulations, Title 22, Division 12 & Chapter 1, 101230(c) Activities is being cited; see LIC 809-D. It was determined that one (1) Type A citation was cited during today’s visit.

LPA Kathy Trinh informed Director Michelle Gjertsen that this report dated 05/15/2026 for Type A citation shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Kathy Trinh informed Director Michelle Gjertsen to provide a copy of this licensing report dated 05/15/2026, 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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, 05/15/2026.

Appeal Rights discussed. Director was provided with 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.

End of Report

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/15/2026 03:22 PM - It Cannot Be Edited


Created By: Kathy Trinh On 05/15/2026 at 02:21 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: MONTESSORI SCHOOL OF SAN CLEMENTE
FACILITY NUMBER: 304371685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2026
Section Cited
CCR
101230

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101230(c) Activities: A teacher-child ratio of one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio...
This requirement was not met as evidenced by:
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Director stated that they will provide a staff training on ratios and nap time procedures to ensure staff understand the rules and regulation and will submit the training agenda and training sign in sheet by due date.
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Based on interview and record review, the facility did not comply with the section cited above given that there were 14 preschool children (13 napping/resting and 1 not napping/resting) in Room 7 with 1 staff for approximately 10 minutes.
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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.
Tina Nguyen
NAME OF LICENSING PROGRAM MANAGER:
Kathy Trinh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
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