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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371438
Report Date: 04/24/2025
Date Signed: 04/24/2025 12:24:34 PM

Document Has Been Signed on 04/24/2025 12:24 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GAOWA MONTESSORI SCHOOLFACILITY NUMBER:
304371438
ADMINISTRATOR/
DIRECTOR:		MINGOLLA, TANYAFACILITY TYPE:
850
ADDRESS:1620 ADAMS AVENUETELEPHONE:
(714) 714-0055
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 96DATE:
04/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Julie Bergman, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On 4/24/2025 at 9:20am, Licensing Program Analyst (LPA) Sarah Garcia and Licensing Program Manager (LPM) Martha Malane conducted a case management- incident visit in response to a self-reported unusual incident report (LIC 624) received on 03/25/25 regarding allegedly children’s personal rights being violated. LPA met with director, Julie Bergman. A walk through of the facility was conducted, and census was taken. Total census was 96 preschool children and 14 staff.

A review of staff criminal clearance records on this date 04/24/2025 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 03/25/2025, a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported that on 3/24/24 at approximately 4:50pm, Staff 1 (S1) was hit by a Child 1 (C1) near the left eye. As result, S1 hit C1 on the left shoulder. Per Reporting Party (RP), C1 had no marks or bruises on shoulder. RP reviewed video footage and confirmed the incident occurred and S1 hit C1. S1 terminated on 3/25/25. Parents of C1 notified on 3/25/25 at 1pm.

During today's inspection, LPA Garcia interviewed 3 staff and 2 children. LPA obtained LIC 624, incident report, and other relevant documentation.

Continued Page 2

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Sarah Garcia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GAOWA MONTESSORI SCHOOL
FACILITY NUMBER: 304371438
VISIT DATE: 04/24/2025
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LPA interviewed 2 children. Child 1 (C1) and Child 2 (C2) were not qualified for an interview.

When LPA asked staff about children with challenging behavior, all staff stated they redirect, talk with the child, and allow the child time to collect themselves.



Based on interviews and record review, it has been determined that S1 violated the child’s personal rights on 3/24/25.

LPA Sarah Garcia informed director, Julie Bergman that this report dated 04/24/2025 document(s) (1) Type A citation(s) which shall be posted for 30 consecutive days as there is an immediate risk(s) to the health, safety, and personal rights to the children in care. Also, LPA Garcia informed director, Julie Bergman to provide a copy of this licensing report dated 04/24/2025 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 kept in the child's file for verification.

An exit interview conducted with Director, Julie Bergman. Notice of Site Visit was provided and must be posted for 30 consecutive days.

End of Report

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Sarah Garcia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 12:24 PM - It Cannot Be Edited


Created By: Sarah Garcia On 04/24/2025 at 10:03 AM
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: GAOWA MONTESSORI SCHOOL
FACILITY NUMBER: 304371438

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/25/2025
Section Cited
CCR
101223(a)(3)

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Section 101223(a)(3)
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation...including but not limited to: interference with functions of daily living...
This requirment was not met as evidenced by...
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Director informed LPA that S1 was terminated on 3/25/25. Director agreed to conduct an all staff training and watch CDSS personal rights video. Director agreed to submit training agenda, staff declarations stating what they have learned, and staff sign in sheet by 5pm on 4/25/25.
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Based on interview, Staff 1 (S1) hit Child 1 (C1) which is an immediate risk to the health, safety, and personal rights to children in care.
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Children’s Personal Rights in Child Care- California Child Care Licensing- https://ccld.childcarevideos.org/

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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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Sarah Garcia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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