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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371442
Report Date: 05/18/2023
Date Signed: 05/18/2023 10:28:43 AM

Document Has Been Signed on 05/18/2023 10:28 AM - 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: 6DATE:
05/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sun (Stella) Chung - DirectorTIME COMPLETED:
10:45 AM
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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 it was discovered that the facility was commingling infant children with preschool age children.

During today's inspection there was 6 infants and 3 staff members in the infant classroom, infants were playing. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the complaint investigation five staff were interviewed on 5/3/23. Staff #1 (S1) disclosed to stay in ratio due to being short staff on 2/2/23, S1 sent 1 infant to the preschool classroom from 4:30pm to 4:45pm and at 5:00pm S1 placed a preschool child in the infant classroom. Staff #4 (S4) stated there has been a couple times that S1 has commingled infant children with preschool age children. Staff #5 (S5) stated there have been at least 2 times according to pictures taken that S1 allowed preschool age children commingling in the infant classroom due to short staff.

Licensee will be cited under the California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101182(2)(a) Issuance/Term of a License. See attached LIC 809D.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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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: 05/18/2023
NARRATIVE
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LPA Odom informed Director Stella that this report dated 5/18/23 document 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.
Also, LPA Odom informed the Director Stella to provide a copy of this licensing report dated 5/18/23 that documents any Type A citation 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 placed in the child's file for verification.

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: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2023 10:28 AM - It Cannot Be Edited


Created By: Carmen Odom On 05/18/2023 at 09:28 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: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2023
Section Cited
CCR
101182(a)(2)

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101182 Issuance/Term of a License
(a) The Department shall issue a license to an applicant in accordance with the provisions of Health... (2) A separate license shall be issued for each component of a combination center. This requirement was not met as evidence by:
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Director stated they will make sure that infant and preschool children do not commingle. Director will make sure there is enough staff available throughout the day but continuing to use Substitute agencies when staff are off. Director will submit a written plan of correction by 5/19/23.
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Based on interviews conducted with staff, records reviewed and obtained pictures, there was at least 2 different dates that S1 had preschool children commingling with infant children in the infant classroom due to short staff. This poses an immediate health and safety risk to the 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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


LIC809 (FAS) - (06/04)
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