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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371150
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:11:22 PM

Document Has Been Signed on 10/25/2022 02:11 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:INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESAFACILITY NUMBER:
304371150
ADMINISTRATOR:KARI KIMBROUGHFACILITY TYPE:
830
ADDRESS:2950 MCCLINTOCK WAYTELEPHONE:
(714) 966-0303
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 21DATE:
10/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Director, Maria Teel TIME COMPLETED:
03:00 PM
NARRATIVE
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A Follow up Case Management Incident inspection was conducted on this day by Licensing Program Analyst (LPA) Dianna Valdez Santana. LPA met with Director, Maria Teel who gave a tour of the facility. Census was taken. There were 21 infant children and 5 staff present upon arrival. A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearances or exemptions and a child abuse index clearance.

The initial inspection was conducted in response to an Unusual Incident Report received on 10/13/2022, in which child #1 (C1) wandered out of the classroom, out of the facility and into the parking lot and street on 10/13/22. Director filed a report with the Department on 10/13/22. This incident was reported to licensing within 24 hours of the incident, compliant with reporting requirement regulations. An inspection was conducted on 10/14/2022, to investigate into this unusual incident.

During the course of the investigation, staff involved in the unusual incident report were interviewed, a physical plant inspection was conducted, and census of children was taken. During the inspection on 10/14/22, the facility had 5 staff and 15 children present.

During the investigation, LPA was able to determine that C1 had wandered away, through the playground and into the classroom, two hallways, out of the facility into the parking lot and into the street. During staff interviews 4 staff including Director stated that C1 got out of the facility and was found by a bystander that works at a neighboring business. LPA was able to take the neighbor/bystander’s statement in which the bystander divulged seeing C1 on their cameras. C1 was starting to wander into the street when the bystander ran after to remove C1 from danger. The bystander stated that cars drive very fast on the curve of the street leaving C1 in immediate danger

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESA
FACILITY NUMBER: 304371150
VISIT DATE: 10/25/2022
NARRATIVE
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The bystander picked C1 up and walked into the daycare’s parking lot and knocked on their door. A staff member met them by the door and tried to get the C1 from bystander, then the Director drove up to the facility. According to bystander and their video footage, C1 was unattended for 3-5 minutes. Bystander admitted to being very upset because c1 could have been run over or taken and that is why bystander insisted they properly inform C1’s parents on what happened and also to the proper authorities. During interviews conducted, it was confirmed that C1 wandered out of the facility and into the street, she wandered approximately 75 feet without supervision.

During record review, LPA obtained copies of the children’s Sign in and Sign out sheets on day of the incident (10/13/22), and the Sign Out sheet revealed C1 was signed in by C1’s authorized representative at 9:00 a.m. and signed out by C1’s authorized representative at 4:09p.m. LPA also obtained the diaper changing log, it reflects that C1’s diaper was changed at 10am before outside play time and not again until 4:00pm before leaving for the day. Showing she missed her 2nd scheduled diaper change at 11:15a.m.-12:00p.m. since she was not accounted for from 11:22a.m. when staff counted children before entering back into classroom and 11:35a.m. when child was found bystander’s camera.

Based on the information obtained during today's inspection regarding this reported incident, it was determined that the facility violated Title 22 Regulations related to Supervision. C1 walked out of the facility, alone, and was unsupervised and unaccounted for approximately 12 minutes until C1 was found by bystander. A violation for a lack of supervision was issued, as this has been determined to be an immediate threat to the children's health and safety. Please see attached LIC 809D and civil penalty pages. An Immediate Civil Penalty is being assessed today.

LPA Valdez Santana informed Director, Maria Teel that this report dated (10/25/22) documents 1 Type A citation. Type A citation shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Valdez Santana informed the Director, Maria Teel to provide a copy of this licensing report dated (10/25/22) that documents any Type A citation(s) 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.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESA
FACILITY NUMBER: 304371150
VISIT DATE: 10/25/2022
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Exit interview conducted and report was reviewed with the Director, Maria Teel.

Notice of Site Visit was posted during the visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. The facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. This report is to be on file and accessible for public review at the facility for at least 3 years.

-Report Ends Here-

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2022 02:11 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 10/25/2022 at 01:39 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: INT'L CHRISTIAN MONTESSORI ACADEMY OF COSTA MESA
FACILITY NUMBER: 304371150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited
CCR
101229(a)(1)

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a) The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement was not met as evidenced
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Per Director, immediately (10/14/22) sent a staff memo reminding staff about supervision procedures and best practices. Staff are to count children before leaving the classroom and before entering back in. Additionally, infant and toddler classroom door handles were replaced with doorknobs that have child safety locks on them
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by: Based on staff interviews, video recording and record review, licensee failed to adequately provide supervision to prevent the child from eloping the facility. This poses an immediate health safety, and personal rights risk to the children in care. Immediate Civil Penalty was assessed.
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 Facility cameras are being reactivated on 10/29/22. A staff training was conducted on 10/21/22 to address best practices while supervising children.

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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:Thuy Ho
LICENSING EVALUATOR NAME:Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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