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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371430
Report Date: 10/27/2025
Date Signed: 10/27/2025 03:50:23 PM

Document Has Been Signed on 10/27/2025 03:50 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MONTESSORI OF LAGUNA NIGUELFACILITY NUMBER:
304371430
ADMINISTRATOR/
DIRECTOR:		PULIYANDA, ANNAFACILITY TYPE:
850
ADDRESS:31171 NIGUEL ROADTELEPHONE:
(949) 661-5437
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 22DATE:
10/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite case management inspection for the purpose of checking into an incident that the facility self reported to our office on 10/20/2025. LPA met with director, Anna Puliyanda. LPA took census. There were a total of 22 preschool children with 3 staff in three different classrooms. The teacher child ratio was as below: one staff with 15 napping children in Room 1, one staff wit 2 napping children in Room 2, and one staff with 5 awake children in Room 3.
According to the self reported incident , 3 year old child sustained a cut on the chin that required 5 stiches while playing outside on the double bike on the passenger side.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Today LPA interviewed the director, staff # 1 and staff # 2 who had knowledge regarding the incident. Staff # 1 (S1) stated S1 was on the playground with S2 supervising 15 preschool children. S1 stated they were few feet away when the incident happened. S1 was aware of their surroundings and observed two children were riding a double bike on the playground. The double bike has a rider and a passenger seat attached to it. Child # 1 (C1) was the passenger and C2 was riding the double bike near the bench area on the playground. When the bike flipped over, C1 fell, C1 got up and ran away towards the play house. S1 stated they followed C1 to check on them. S1 noticed a cut under the C1's chin. They applied a compress to stop the bleeding. C1's representative was informed. Continued on page 2
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MONTESSORI OF LAGUNA NIGUEL
FACILITY NUMBER: 304371430
VISIT DATE: 10/27/2025
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S2 stated they were also close by when the incident happened. S2 believed the double bike hit the bench area when C2 was riding it. That is the time C1 lost balance and the bike flipped over.

LPA requested to watch the video footage of the incident which happened on 10/20/2025 around 3:00 pm. LPA observed C2 was riding the double bike while C1 was sitting next to C2 in the passenger seat. It was not clear enough in the video footage the cause of C2 loosing balance that made C1 fell on the concrete when the bike flipped over. LPA did not observe any child pushing the double bike. LPA did not interview children due to their age being young to be qualified.

LPA also checked the double bike with the passenger. LPA found that the bike was in good shape. According to S3 they stopped using the double bike riding after this incident to prevent accidents.

Based on the interviews with the director, two staff who were present and close to children at the time of incident, and reviewing the video footage recorded by the outdoor cameras of the incident dated 10/20/2025, the incident was not fount out to be due to lack of staffs' supervision and it was an unfortunate accident.

In the areas that were evaluated, no deficiency was observed of the California Code of Regulations, Title 22, Division 12 on this inspection.

A notice of site visit was given to director, Anna Puliyanda and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to post will result in Civil Penalties of $100.00.

Exit interview conducted and report was reviewed with the director, Anna Puliyanda.

End of report

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
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