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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371442
Report Date: 05/03/2023
Date Signed: 05/03/2023 01:15:57 PM

Document Has Been Signed on 05/03/2023 01:15 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: 13CENSUS: 12DATE:
05/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sun Chung - DirectorTIME COMPLETED:
01:30 PM
NARRATIVE
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An unannounced case management report was initiated on today’s date by Licensing Program Analyst (LPA) Odom, during a complaint investigation visit LPA observed a baby bouncer in the infant center.
During today's inspection there were 12 infants and 4 staff members in the outdoor playground.
A review of staff records on this date (5/1/23) indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

At 9:00am upon arrival LPA Odom observed an infant on the baby bouncer outdoors during AM outdoor play time. LPA took picture. There were 3 staff supervising 12 infants outside while 1 staff was inside the classroom cleaning. When questioned regarding baby bouncer not being allowed in the facility, Director seemed surprised. Director stated C1's parent brought the bouncer because C1 cannot walk yet. Director stated they removed the baby bouncer from the facility. Based on LPA’s observation and interview conducted with Director it was determined that the facility was using a baby bouncer in the infant center.

Licensee will be cited under the California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101239(n)(1) Fixtures, Furniture, Equipment, and Supplies. See attached LIC 809D.

This report cites Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Exit interview was conducted with Director Sun Chung. Notice of Site Visit was posted during the visit. Licensee was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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Document Has Been Signed on 05/03/2023 01:15 PM - It Cannot Be Edited


Created By: Carmen Odom On 05/03/2023 at 11:53 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: 304371442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2023
Section Cited
CCR
101239(n)(1)

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101239 Fixtures, Furniture, Equipment and Supplies (n) Furniture and equipment shall be maintained in good condition, free of...
(1) A baby walker shall not be allowed on the premises of a child care center in accordance with Health and Safety Code Sections 1596.846(b) and (c). This requirement was not met by:
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Director stated they removed the baby bouncer from the infant center. They will no longer accept baby equipement that is not allowed in the childcare centers. Traini staff. Director will submit a written plan of correction by 5/4/23 to LPA Odom.
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Based on LPA's observation, picture taken and director interview. The infant staff was utilizing a baby bouncer on infant center since February. C1 was observed on the baby bouncer during outdoor playtime. This imposes an immediate health and safety risk to children in care.
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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:Judy Hanson
LICENSING EVALUATOR NAME:Carmen Odom
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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