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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370501
Report Date: 01/18/2023
Date Signed: 01/18/2023 04:55:39 PM

Document Has Been Signed on 01/18/2023 04:55 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:MY FIRST MONTESSORIFACILITY NUMBER:
304370501
ADMINISTRATOR:WENDY MARTINFACILITY TYPE:
850
ADDRESS:19118 BROOKHURST STREETTELEPHONE:
(714) 962-2620
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 231TOTAL ENROLLED CHILDREN: 231CENSUS: 80DATE:
01/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Wendy Martin, DirectorTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tran and LPA Chan conducted a case management inspection to follow up on a self-report unusual incident that was submitted to CCL Regional Licensing Office on 12/14/2022. It was reported by Wendy Newton, Director. According to Mrs. Newton, the unusual incident occurred on 12/13/2022, when child #1 (C1) sustained an injury on the right elbow from falling while the climbing ladder, in the play yard during outside time.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.

During today's inspection staff members were interviewed and a tour of the facility was conducted. There were a total of 80 children and 20 staffs in different classrooms. Facility meets capacity and staff-to-child ratio. LPA interviewed the staffs that were present at the incident. All staff were providing consistent responses in regarding to the supervision provided during the incident and the staff to child ratio during the incident were met.

Based on interviews with staff on 12/20/2022 and on 01/18/2022 and record review of staffing schedule, the facility is within compliance of Title 22 Division 12 of the California Code of Regulations.

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. 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 was conducted. The Notice of Site Visit was posted. Director was advised the Notice of Site Visit must be posted for 30 days or 100$ Civil Penalty will be assessed.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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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