191201904-9-15-2022-58-CC-SMAZ-CJAR68-20220915124418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191201904
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:45:00 PM

Document Has Been Signed on 09/15/2022 12:45 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:	LAUREL HALL NURSERY SCHOOL		FACILITY NUMBER:	191201904
ADMINISTRATOR:	KESTER, SAMANTHA		FACILITY TYPE:	850
ADDRESS:	11850 CALVERT ST.		TELEPHONE:	(818) 762-1370
CITY:	N. HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	104	CENSUS: 82	DATE:	09/15/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Leslie Diaz, Director		TIME COMPLETED:	01:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 09/15/2022, Licensing Program Analyst (LPA) Sabrina Martinez arrived at Laurel Hall Nursery School to conduct an unannounced case management visit. LPA Martinez was met by Director Leslie Diaz. LPA Martinez informed director about the purpose of the visit and was guided on a tour of the facility. There were 82 children during today’s visit.

The facility has been identified to have 4 water outlets 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 09/14/2022, LPA Martinez contacted Director Leslie Diaz and informed Director of the testing results. LPA also provided Director with the Written Directives in PIN 21-21 CCP for Lead Water Testing.

Director provided LPA with a copy of the results of lead water sample testing conducted by Pace Analytical Environmental Sciences. Testing was conducted on 07/05/2022 and samples were received by the laboratory on 07/12/2022. Per the report, the following water outlets yielded the following results:

1.) Drinking Fountain (Outside of Room 1):11 ppb

2.) Drinking Fountain (Inside of Room 1): 35 ppb

3.) Drinking Fountain (Inside of Room 2): 24 ppb

4.) Drinking Fountain (Inside of Room 5):11 ppb

During today’s inspection, LPA Martinez obtained the following documents: External Water Sample Self-Certification Form (LIC 9275), Signed and dated Child Care Center Sampling Checklist Form (LIC 9276), Facility Sketch (fully labeled with locations of all water outlets), and photos of water outlets. LPA will upload the documents to the CA State Water Resources Control Board, Division of Drinking Water Database (DDW) database.

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina Martinez	TELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 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: LAUREL HALL NURSERY SCHOOL	FACILITY NUMBER: 191201904
	VISIT DATE: 09/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During today’s visit LPA Martinez conducted a tour of the facility and observed 9 water outlets that were bagged, taped, and labeled with the “Do Not Use” signage. These outlets were identified on the facility sketch. Director stated that the children do not consume water from the water outlets. All drinking fountains have been out of use and have been shut off since March 2020. Director stated that bottled water is provided for children and each child bring their own water bottle as well. Director stated that the kitchen faucets are not currently in use because pre-packaged snacks are being provided and children bring their own lunch from home.

Director stated that the facility will exclusively use bottled water, and no water outlets are used for drinking. Director stated that the facility will request for a waiver to waive sampling and testing requirement. Director was reminded that waivers will be considered on a case-by-case basis.

Based on observation, interviews and supportive documents it has been determined that Laurel Hall Nursery School 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 07/05/2022 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 09/15/2022. 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 Director. Director Leslie Diaz demonstrated that all required actions were taken to correct the violation once discovered. As mentioned earlier Director submitted all required licensing forms, supportive documents and plan of correction. Deficiency cleared today, 09/15/2022.

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

LPA Martinez provided technical assistance and discussed wavier for drinking water as outlined in PIN.

Exit interview conducted and appeal right explained. A copy of this report, appeal rights, and Notice of Site Visit provided to Director Leslie Diaz.

SUPERVISOR'S NAME: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina Martinez	TELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/15/2022 12:45 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: LAUREL HALL NURSERY SCHOOL	FACILITY NUMBER: 191201904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2022 Section Cited	1 2 3 4 5 6 7	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: Lead water testing samples taken on 07/05/2022 revealed that levels of lead
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Rita Ramos	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina Martinez	TELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3