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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371441
Report Date: 03/24/2022
Date Signed: 03/24/2022 12:13:56 PM

Document Has Been Signed on 03/24/2022 12:13 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:ACACIA MONTESSORI SCHOOLFACILITY NUMBER:
304371441
ADMINISTRATOR:CHUNG, SUNFACILITY TYPE:
850
ADDRESS:1701 EAST CHAPMAN AVENUETELEPHONE:
(336) 870-2176
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 54TOTAL ENROLLED CHILDREN: 38CENSUS: 20DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sun Chung, Licensee/DirectorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Stacy Torrence conducted an onsite inspection for the purpose of an Annual Random. LPA and staff toured the facility inside and outside and the floor and yard plan (LIC 999) were verified. Census was taken. The overall census observed was 20 preschool children, with 3 staff supervising. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:00a.m.- 6:00p.m., Monday through Friday. 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.

During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Facility provides breakfast, lunch, and PM snacks. The facility’s kitchen was clean and sanitary. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by children bringing their own water bottles from home with the child’s name on it, and the facility provides refills with filter water. The children's bathrooms are clean and sanitary. Children nap on cots, and bedding is stored individually and is taken home weekly to be washed by the parents. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

Staff files were reviewed for staff present during the facility inspection on this date, 3 out of 3 staff files were reviewed.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ACACIA MONTESSORI SCHOOL
FACILITY NUMBER: 304371441
VISIT DATE: 03/24/2022
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Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for the 3 staff were reviewed and 2 staff were not in compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Staff #3 did not have a update mandated reporter training certificate. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 05/2022.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 12 children's files were reviewed. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed and facility was within compliance. The person who signs the child in and out uses their full legal signature and records the time of the day.

LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. On 12/29/2021, owner/director reported that a car ran into their south playground fence; therefore, this playground is no longer being used by the facility until the owner install a stronger fence. The surface of the outdoor activity space was well maintained and free of hazards. Appropriate cushioning material was observed around and under play equipment. Drinking water in the outdoor activity space is provided by children bringing their own water bottles from home, and the facility provide refills. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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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: ACACIA MONTESSORI SCHOOL
FACILITY NUMBER: 304371441
VISIT DATE: 03/24/2022
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The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov facility representative may request to be added to an email list to receive a Quarterly Update from www.ccld.ca.gov and select Receive Important Updates link. The licensee was informed that Licensing information are available at www.cdss.ca.gov/inforesources/community-care-licensing.

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Based on LPAs record reviews the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101216.1(g) Teachers Qualification, and H&S 1596.7995(a)(1) Immunizations, are being cited on the attached LIC 809D, and Technical Violation for H&S 1596.8662(b)(1).

An Inspection and exit interview were completed with facility representative. The report was reviewed and discussed. Appeal Rights was 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.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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: ACACIA MONTESSORI SCHOOL
FACILITY NUMBER: 304371441
VISIT DATE: 03/24/2022
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The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

End of Report

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2022 12:13 PM - It Cannot Be Edited


Created By: Stacy Torrence On 03/24/2022 at 10:46 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: ACACIA MONTESSORI SCHOOL
FACILITY NUMBER: 304371441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff records were missing proof of immunizations which poses a potential health risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
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During the course of the inspection, licensee was able to produce proof of immunizations for staff members by requesting staff to acquire their records, while LPA was there.
Type B
Section Cited
CCR
101216.1(g)
Teacher Qualifications and Duties
(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff did not have transcripts which poses a potential health risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
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During the course of the inspection, licensee was able to produce staff's transcripts by requesting staff to acquire transcipts, while LPA was there.
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:Stacy Torrence
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


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