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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300606752
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:20:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2024 and conducted by Evaluator Soo Jin Jung
COMPLAINT CONTROL NUMBER: 06-CC-20240621142824
FACILITY NAME:MONTESSORI ON THE LAKEFACILITY NUMBER:
300606752
ADMINISTRATOR:EVEREST, JULIEFACILITY TYPE:
850
ADDRESS:24291 MUIRLANDS, SUITES 1 & 2TELEPHONE:
(949) 855-5630
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:77CENSUS: 33DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director Julie EverestTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff do not conduct disaster drills every six months
INVESTIGATION FINDINGS:
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On 9/6/2024, Licensing Program Analyst (LPA), Christine Jung conducted an unannounced visit to the facility to deliver findings for a complaint that was received at the Orange County Regional Child Care Licensing Office. LPA met with Director, Julie Everest, and explained the reason for the visit. LPA was led on a tour of the facility and observed a total of 33 children and 8 staff.

On 6/21/2024, the Orange County Regional Child Care Licensing Office received a complaint with the allegation listed above: Reporting Party (RP) alleged that staff do not conduct disaster drills every six months.

On 6/24/24, LPA made an unannounced visit to the facility and conducted staff interviews and record review. Facility representative provided LPA with the emergency drill log which showed that it had been more than six months between the last two emergency drill dates.
(Go to Page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 06-CC-20240621142824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ON THE LAKE
FACILITY NUMBER: 300606752
VISIT DATE: 09/06/2024
NARRATIVE
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The Orange County Regional Child Care Licensing Office has investigated the complaint alleging staff do not conduct disaster drills every six months. Based on information gathered from LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is substantiated. California Code of Regulations, Title 22, Division 12 & Chapter 1, Section 101174(d) Disaster and Mass Casualty Plan has been cited; see LIC 9099D for Type B deficiency.

Due to technical difficulties, LPA emailed the report to the director.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Julie Everest.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 06-CC-20240621142824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ON THE LAKE
FACILITY NUMBER: 300606752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
101174(d)
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101174(d) Disaster and Mass Casualty Plan: Disaster drills shall be conducted at least every six months. This requirement was not met as evidenced by:

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Director stated all facilities will be conducting drills every four months and logging it in the emergency drill log.
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Based on interviews and record reviews, the licensee did not conduct an emergency drill once at least every six months, which poses a potential risk to the health, safety, and personal rights of the clients 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.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2024 and conducted by Evaluator Soo Jin Jung
COMPLAINT CONTROL NUMBER: 06-CC-20240621142824

FACILITY NAME:MONTESSORI ON THE LAKEFACILITY NUMBER:
300606752
ADMINISTRATOR:EVEREST, JULIEFACILITY TYPE:
850
ADDRESS:24291 MUIRLANDS, SUITES 1 & 2TELEPHONE:
(949) 855-5630
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:77CENSUS: 44DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director Julie EverestTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff without ECE units are left alone with children
INVESTIGATION FINDINGS:
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On 9/6/2024, Licensing Program Analyst (LPA), Christine Jung conducted an unannounced visit to the facility to deliver findings for a complaint that was received at the Orange County Regional Child Care Licensing Office. LPA met with Director, Julie Everest and explained the reason for the visit. LPA was led on a tour of the facility and observed a total of 33 children and 8 staff.

On 6/21/2024, the Orange County Regional Child Care Licensing Office received a complaint with the allegation listed above: Reporting Party (RP) alleged that staff without Early Childhood Education (ECE) units are left alone with children.

On 6/24/24, LPA made an unannounced visit to the facility and interviewed staff and children. Facility representative provided LPA with documents pertinent to the investigation.
On 7/1/2024, LPA made an unannounced visit to the facility. LPA interviewed additional staff and conducted record reviews. During record reviews, LPA observed that Staff 6 (S6) did not have ECE units on file.
(Go to page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 06-CC-20240621142824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ON THE LAKE
FACILITY NUMBER: 300606752
VISIT DATE: 09/06/2024
NARRATIVE
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On 8/23/24, S6 confirmed during their interview that they do not have ECE units completed yet have supervised children alone. S6 stated they supervised children alone in June 2024 during their closing shift. This is a violation of Teacher Aide Qualifications and Duties.

The Orange County Regional Child Care Licensing Office has investigated the complaint alleging staff without ECE units are left alone with children. Based on information gathered from LPA’s interviews, observations, and record review, the preponderance of evidence standard has been met, therefore the allegation is substantiated. California Code of Regulations, Title 22, Division 12 & Chapter 1, Section 101216.1(b)(1) Teacher-Child Ratio has been cited; see LIC 9099D for Type A deficiency.

LPA Jung informed Director, Julie Everest, that this report dated 9/6/2024 documents 1 Type A citation. Type A citations 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 informed the Director, Julie Everest, to provide a copy of this licensing report dated 9/6/2024 that documents any 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. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00.

Due to technical difficulties, LPA emailed the report to the director.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Julie Everest.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 06-CC-20240621142824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ON THE LAKE
FACILITY NUMBER: 300606752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
101216.1(b)(1)
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101216.1 Teacher Qualifications and Duties: A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent ... This requirement was not met as evidenced by:
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No staff members without the proper units will be left alone with children.
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Based on interviews and record reviews, the licensee did not ensure staff completed the minimum number of ECE units or equivalent, which poses an immediate risk to the health, safety, and personal rights of the clients 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.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2024 and conducted by Evaluator Soo Jin Jung
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20240621142824

FACILITY NAME:MONTESSORI ON THE LAKEFACILITY NUMBER:
300606752
ADMINISTRATOR:EVEREST, JULIEFACILITY TYPE:
850
ADDRESS:24291 MUIRLANDS, SUITES 1 & 2TELEPHONE:
(949) 855-5630
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:77CENSUS: 33DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director Julie EverestTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Lack of supervision resulted in child wandering away from facility
Staff do not ensure that classrooms maintain correct staff to child ratios throughout the day
Staff do not ensure medications are stored inaccessible to children
Staff do not ensure children meet immunization requirements
Staff do not ensure toxic cleaning products are stored inaccessible to children
INVESTIGATION FINDINGS:
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On 9/6/2024, Licensing Program Analyst (LPA), Christine Jung conducted an unannounced visit to the facility to deliver findings for a complaint that was received at the Orange County Regional Child Care Licensing Office. LPA met with Director, Julie Everest, and explained the reason for the visit. LPA was led on a tour of the facility and observed a total of 33 children and 8 staff.

On 6/21/2024, the Orange County Regional Child Care Licensing Office received a complaint with the allegations listed above: Reporting Party (RP) alleged that (1) lack of supervision resulted in child wandering away from facility, (2) staff do not ensure that classrooms maintain correct staff to child ratios throughout the day, (3) staff do not ensure medications are stored inaccessible to children, (4) staff do not ensure children meet immunization requirements, (5) staff do not ensure toxic cleaning products are stored inaccessible to children.

(Go to Page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 06-CC-20240621142824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ON THE LAKE
FACILITY NUMBER: 300606752
VISIT DATE: 09/06/2024
NARRATIVE
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On 6/24/24, LPA made an unannounced visit to the facility and interviewed staff and children. LPA was provided with documents pertinent to the investigation. All staff stated they have never observed a child wandering away from the facility and have never observed classrooms out of ratio. All staff also stated that medications are stored either in the front office or in cabinets that are out of reach of children in the classrooms. During LPA’s visit, medications were observed to be stored in the front office, and none were observed in the classrooms.

On 7/1/2024, LPA made an unannounced visit to the facility. LPA interviewed additional staff and conducted record reviews. During LPA’s record review, all children’s files reviewed met immunization requirements. Also, LPA did not observe toxic cleaning products in areas that were accessible to children, and all staff interviewed stated they only use soap and water solution to clean in the classrooms.

On 8/21/24 and 8/23/24, LPA conducted parent interviews. All parents interviewed stated their children were enjoying the facility’s program, and they praised the staffs’ interactions with the children.

The Orange County Regional Child Care Licensing Office has investigated the complaint alleging (1) lack of supervision resulted in child wandering away from facility, (2) staff do not ensure that classrooms maintain correct staff to child ratios throughout the day, (3) staff do not ensure medications are stored inaccessible to children, (4) staff do not ensure children meet immunization requirements, (5) staff do not ensure toxic cleaning products are stored inaccessible to children. Based on information gathered from LPA’s interviews, observations, and record reviews, although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Due to technical difficulties, LPA emailed the report to the director.

No deficiencies cited.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Julie Everest.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8