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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300610669
Report Date: 01/16/2024
Date Signed: 01/16/2024 12:54:52 PM

Document Has Been Signed on 01/16/2024 12:54 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:IVYCREST MONTESSORI PRIVATE SCHOOLFACILITY NUMBER:
300610669
ADMINISTRATOR:AIDA KINGFACILITY TYPE:
850
ADDRESS:2025 E. CHAPMAN AVENUETELEPHONE:
(714) 879-6091
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 214TOTAL ENROLLED CHILDREN: 189CENSUS: 162DATE:
01/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Director, Aida KingTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cindy Nguyen and Vivian Trinh conducted an unannounced case management inspection due to a deficiency discovered during staff interviews. Upon arrival LPAs met with Aida King, Director who accompanied LPAs on a tour of the facility. Census was taken as follows: 31 toddlers, 131 preschool children with 22 staff members. A review of staff criminal records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearance or exemption and a child abuse index clearance.

On 08/31/2023, during an inspection to the facility, interviews with the staff, it was discovered that an unusual incident report LIC624 was not created and submitted. On 08/11/2023, a staff member handled a child in a rough manner resulting in an injury. The incident was documented internally but there was no record of the facility reporting the incident to the Community Care Licensing Department.

Based on the interviews conducted with staff members the following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101212(d)(1)(B) Reporting Requirement. The deficiency is being cited on the attached 809D.



Exit interview was conducted with Director Aida King. The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalty of $100. The Director was provided with a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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Document Has Been Signed on 01/16/2024 12:54 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 01/16/2024 at 12:24 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: IVYCREST MONTESSORI PRIVATE SCHOOL
FACILITY NUMBER: 300610669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
101212(d)(1)(B)

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101212(d)(1)(B) Reporting Requirements (d) Upon the occurrence, during the operation...(d)(2) below shall be submitted to the Department ... (1) Events.. (B) Any injury to any child that requires medical treatment. This requirement is not met as evidenced by:
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Director states they will follow licensing procedures to submit future incident reports. Director will also train staff (listed as designees of responsibility) of protocol and email LPA training sheet and attendance sheet by POC date.
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Based on LPA interview with the staff members on 08/31/2023, a staff handled a child in a rough manner. Facility documented the incident but did not report it to the local licensing agency. This is a potential risk to the health, safety, or personal rights of 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:Patricia Magana
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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