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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201890
Report Date: 02/27/2023
Date Signed: 02/27/2023 12:03:20 PM


Document Has Been Signed on 02/27/2023 12:03 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:KIRK O'THE VALLEY PRESCHOOLFACILITY NUMBER:
191201890
ADMINISTRATOR:BECKY JENKINSFACILITY TYPE:
850
ADDRESS:19620 VANOWEN STTELEPHONE:
(818) 344-1242
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:124CENSUS: 43DATE:
02/27/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hillary Felder - Administrative DirectorTIME COMPLETED:
12:20 PM
NARRATIVE
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On 02/27/2023, Licensing Program Analyst (LPA) Suzette Ornelas arrived at Kirk O'The Valley Preschool to
conduct an unannounced case management visit. LPA Ornelas was met by Administrative Director, Hillary Felder. LPA informed director about the purpose of the visit and was guided on a tour of the facility. LPA observed 43 children and 11 adults during today’s visit.

The facility has been identified to have 1 water outlet with an Action Level Exceedance (ALE) in the amount of
lead in the water being 5.5 ppb, or greater. The purpose of today’s visit is to ensure that faucets are not in use and there is potable source of water for children and staff at the facility.

On 02/17/2023, LPA Ornelas contacted Administrative Director Hillary Felder and informed Director of the testing results. LPA Ornelas obtained the following documents from director via email: External Water Sample Self-Certification Form (LIC 9275), Signed and dated Child Care Center Sampling Checklist Form (LIC 9276), and Facility Sketch (fully labeled with locations of all water outlets).

Director provided LPA with a copy of the results of lead water sample testing conducted on 01/21/2023. Per the report, the following water outlets yielded the following results:

1.) Sink/Faucet D (Inside Room 3): 29 ppb

During today’s visit LPA Ornelas conducted a tour of the facility and observed 1 water outlet that was
bagged, taped, and labeled with the “Do Not Use” signage. LPA obtained photos of water outlet that was identified on the facility sketch. Director stated that the children do not consume water from the water outlet. Director further stated that there is a Culligan water dispenser along with a water filter dispenser located in the kitchen that is used to refill children's refillable water bottles throughout the day as needed.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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 02/27/2023 12:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: KIRK O'THE VALLEY PRESCHOOL
FACILITY NUMBER: 191201890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2023
Section Cited

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California Lead Action Level at Child Care
Centers. A result with values of 5.5 ppb or
greater shall be deemed an Action Level
Exceedance.

This requirement is not met as evidenced by:
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Faciilty has replaced faucets/ outlets, identified with an Action Lead Exceedance of 5.5 ppb or over. These outlets will not be accessible for use until a retest has occurred. Director will send LPA a copy of the re-test summary once completed on or before . 03/31/2023
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Lead water testing samples taken on
01/21/2023 revealed that levels of lead were beyond the allowable amount deemed by the State of California. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons 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: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KIRK O'THE VALLEY PRESCHOOL
FACILITY NUMBER: 191201890
VISIT DATE: 02/27/2023
NARRATIVE
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Based on observation, interviews and supportive documents it has been determined that Kirk O'The Valley Preschool violated Child Care Licensing Regulation Division 12, Chapter 1, Subchapter 5 101700.3 (b)(1)
California Lead Action Level at Child Care Centers. A result with values of 5.5 ppb or greater shall be deemed
an Action Level Exceedance.

Lead water testing samples taken on 01/21/2023 revealed that levels of lead were beyond allowable amount deemed by the State of California. This facility is being cited (1) deficiency during today’s visit 02/27/2023. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care. Refer to LIC 809-D for deficiency page.

LPA discussed Proof of Correction (POC) with Administrative Director. Administrative Director demonstrated that all required actions were taken to correct the violation once discovered. Director replaced fixture D in Room 3 with low level certified NSF/ANSI 61-G lead fixture; Krowne 14-812L. Director will proceed with flushing requirements 4 times daily for 3 weeks until a retest visit is scheduled. Once retest results are obtained, Administrative Director will email results to LPA. As mentioned earlier Director submitted all required licensing forms, supportive documents and provided LPA with a Plan of Correction of 2/27/2023.

For more information, go to the California Childhood. Lead Poisoning Prevention Branch’s website at
www.cdph.ca.gov/programs/clppb or call them at (510) 620-5600. Please see Provider Information Notice
(PIN) 20-01-CCP for more information about lead toxicity prevention.

Exit interview conducted and appeal rights explained. A copy of this report, appeal rights, and Notice of Site
Visit provided to Administrative Director.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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