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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270541
Report Date: 09/01/2026
Date Signed: 09/01/2026 12:46:27 PM

Document Has Been Signed on 09/01/2026 12:46 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:BACK BAY MONTESSORIFACILITY NUMBER:
304270541
ADMINISTRATOR/
DIRECTOR:		PRIYA EDIRIWIRAFACILITY TYPE:
850
ADDRESS:398 UNIVERSITY DRIVETELEPHONE:
(949) 548-3771
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 67TOTAL ENROLLED CHILDREN: 48CENSUS: 38DATE:
09/01/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Facility Representative, Priya EdiriwiraTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 09/01/2026, Licensing Program Analyst (LPA) Deschampe arrived at the Child Care Center (CCC) at 9:24AM to conduct an unannounced case management inspection in response to a self-reported Unusual Incident Report (UIR)(LIC 624), received on 08/14/2026. LPA was granted entry to the CCC by Facility Representative/Director (FR), Priya Ediriwira. FR guided LPA through the CCC and obtained the following: Census was 38 preschool children and 9 staff, with a total enrollment of 48 preschool children, with various enrollment schedules.

Around 10:15AM, the CCC owner, Karen Caves arrived at the CCC. Karen spoke to LPA in an argumentative tone regarding LPA’s purpose at the CCC, LPA’s length of time at the CCC, and interrupted a staff interview to ask LPA how much longer LPA would be at the CCC. The owner left around 10:45AM.

On 08/14/2026, an UIR was filed with the Orange County Regional Office (OCRO) by the FR to self-report an incident on 08/14/2026, around 11:20AM. Child 1 (C1) was climbing up the steps to the slide when C1 fell, hitting their chin on the steps. C1 sustained a cut under the chin. Director put ice and a bandage on the cut and then noticed C1 had also bit their tongue. Authorized representative was called and took C1 to urgent care. C1 had sustained an injury on the chin earlier this year, with authorized representatives. At the time of the incident, there were 12 children and 2 staff on the playground.

During the investigation, LPA made observations, interviewed staff, obtained and reviewed pertinent documentation including children’s records (medical records), facility records, and correspondence between the CCC and authorized representative.

Thuy Ho
Susan Deschampe
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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: BACK BAY MONTESSORI
FACILITY NUMBER: 304270541
VISIT DATE: 09/01/2026
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During the staff interviews, Staff 1 (S1) stated on 08/14/2026, the CCC was having a water play day with the sprinkler placed near the playground climbing structure in order for the the slide would get wet, because the children like that. C1 was climbing the structure with bare feet. S1 witnessed C1 climb the playground climbing structure steps, slip, and hit their chin on the steps. S1 immediately attended to C1 and provided care. The director did not witness the incident but provided care once C1's injury was brought to her attention. The director received updates from the the authorized representative regarding follow-up care for C1. C1's scheduled final day at the CCC was 08/14/2026.

Based on the interviews, records reviewed, and observation during today’s inspection, no deficiencies were observed of the California Code of Regulations Title 22 Division 12, at the time of the inspection.

Exit interview conducted and report was reviewed with the facility representative, Priyangani Ediriwira. A notice of site visit was given to the facility representative and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

End of report

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
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