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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371442
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:07:32 PM

Document Has Been Signed on 03/24/2022 03:07 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:
304371442
ADMINISTRATOR:CHUNG, SUNFACILITY TYPE:
830
ADDRESS:1701 EAST CHAPMAN AVENUETELEPHONE:
(336) 870-2176
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 13TOTAL ENROLLED CHILDREN: 10CENSUS: 7DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Sun Chung, Licensee/DirectorTIME COMPLETED:
03:15 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. There was seven infants, with 2 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 6:30a.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. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The bins had tight fitting covers. The napping area is separated from the activity area and has sufficient infant napping equipment. There were no baby walkers observed on the premises. The changing table is within arm reach of a sink. Bottles and dishes are labeled with the current date and infant’s names. 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, 2 out of 2 staff files were reviewed. Health screening and immunizations as required were reviewed. 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.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2022
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: 304371442
VISIT DATE: 03/24/2022
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Proof of immunization against pertussis, measles for the two staff were reviewed and within 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. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 02/01/2024.

Infant’s records were reviewed, and there was a separate, complete and current record for each child. A random sample of four infant’s files were reviewed. LPA observed 4 infants from 0-12 months. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan in the infant’s files. In the areas reviewed the infant’s files were found not to be in full compliance. LPA did not observe the Infant Needs and Service Plan in the infant’s files or in the infant’s classroom. LPA did not observe a 15-minute check document in the infant’s files or in the classroom. Sign in/out procedure was reviewed for 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. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material made of soft mats around the climbing equipment, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by bottles/sippy cups and pitchers for 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: 304371442
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.

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 101429(a)(2)(B) Responsibility for Providing Care and Supervision for Infants and 101419.2(a) Infant Needs and Service Plan, are being cited on the attached LIC 809D,

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
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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: 304371442
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
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Document Has Been Signed on 03/24/2022 03:07 PM - It Cannot Be Edited


Created By: Stacy Torrence On 03/24/2022 at 02:36 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: ACACIA MONTESSORI SCHOOL
FACILITY NUMBER: 304371442

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that staff did not document the every 15 minute check of infants which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Per Director, she will email LPA a copy of the 15-minute sleep log, by POC due date of 04/01/2022.
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that staff did not complete an Infant Needs and Service Plan for the infants in care which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Per director, she will email LPA a copy of an Infant Needs and Service Plan for each infant in care by POC due of 04/01/2022.
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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