191290431-2-15-2023-30-CC-DWHE-CP3TQN-20230215135613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290431
Report Date: 02/15/2023
Date Signed: 02/15/2023 01:56:21 PM

Document Has Been Signed on 02/15/2023 01:56 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	VOA/MAUD BOOTH FAMILY CENTER		FACILITY NUMBER:	191290431
ADMINISTRATOR:	PEREZ, M BONILLA, S		FACILITY TYPE:	850
ADDRESS:	11243 KITTRIDGE STREET		TELEPHONE:	(818) 980-2287
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	132	CENSUS: 60	DATE:	02/15/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Nury Gonzalez		TIME COMPLETED:	01:00 PM

NARRATIVE

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On 02/15/2023 Licensing Program Analyst (LPA) Doris Whitmore arrived at VOA/ Maud Booth Family Center to conduct an unannounced case management visit. LPA Whitmore was met by Education Coordinator Nury Gonzalez. LPA Whitmore informed the Education Coordinator about the purpose of the visit and was guided on a tour of the facility. There were 12 teachers, and 60 children present during the visit.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires all licensed Child Care Centers (CCC’s) constructed before January 1,2010 to test their drinking water for lead contamination between January 1, 2020, and January 1, 2023, and then every five years after the date of the first test.

The Department was notified that the facility has been identified to have water outlets with an Action Level Exceedance (ALE) in the amount of lead in the water being 5.5 parts per billion (pbb), or greater. The purpose of today’s visit is to ensure that water outlets are not in use and there is a potable source of water for children and staff at the facility.

On 02/15/2023, LPA Whitmore at the time of the visit received the following documents: the Water Testing Result, Facility Sketch, Pictures, External Water Sampler Self- Certification form (LIC9275) Child Care Sampling Checklist form (LIC9276), Analytical Report, Lead Chain Custody, Environmental Laboratory Accreditation, & Lead Related Construction Certificate. Lead Water sample testing conducted by Terra Environmental. The facility was prep for water sampling on 12/20/22, tested 12/21/2022. The lab collected the water sample on 12/21/2022. The facility received the results on 01/03/2023. Samples submitted to the Terra Environmental 12/22/22. Per the report, the following water outlets yielded the following reports:

Handwashing Sink Room 3 Sink A ppb.10.7

During toddy’s visit LPA observed that the facility currently is not using the hand washing sink in the classroom. Education Coordinator shared with the LPA that a Maintenance Request form was submitted on 02/3/2023. The date the new faucet was replaced was 02/07/2023. Education Coordinator Nury Gonzalez provided LPA with documentation. LPA Whitmore also received the receipt of purchase for new faucet that was purchased on 02/06/2023.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris Whitmore	TELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: VOA/MAUD BOOTH FAMILY CENTER	FACILITY NUMBER: 191290431
	VISIT DATE: 02/15/2023

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LPA will upload documents to the CA State Control Board, Division of Drinking Water (DDW) data base. During today's visit LPA Whitmore conducted the tour of the facility and observed the handwashing sink that was tested and replaced LPA took pictures of the faucet.

Based on observation, interviews and supportive documents it has been determined that VOA/ Maud Booth Family Center violated Child Care Licensing Regulation Division 12 Chapter 1, Subchapter 5 1017003 (b) (1) California Lead Action Level at Child Care Centers. A result with values of 5.5ppb or greater shall be deemed an Action Level Exceedance. Lead water testing samples taken on 12/21/2022 reveled 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 02/15/2023. This is a type B violation which poses a potential Health, Safety, or Personal Rights risk to persons in care. Refer to LIC809-D for deficiency page.

LPA discussed Proof of Correction (POC) with Education Coordinator Nury Gonzalez.

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 was conducted, report was reviewed with Education Coordinator Nury Gonzalez licensee was provided a copy of the report and appeal rights.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris Whitmore	TELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2023 01:56 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: VOA/MAUD BOOTH FAMILY CENTER	FACILITY NUMBER: 191290431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/15/2023 Section Cited	1 2 3 4 5 6 7	California Lead Action Level at Child Care Centers: A result with values of 5.5ppb or greater shall be deemed an Action Level Exceedance. This requirenment not met by evidence by:lead water testing samples taken on 12/21/2022 reveled that levels of lead were beyond allowable amount deemed by the State of California. 1 handwashing sink have lead exceddance level Room 3 sink 10.7	1 2 3 4 5 6 7	Facility has replaced faucet/outlet identified with an Action Lead Exceedance of 5.5ppb or over. Mainteanace Request was submitted 02/02/2023. Faucet replaced 02/07/2023. Invoce Date for Faucet purchased 02/06/2023. Handwashing sink will not be used until a retest has occurred.Education Coordinator will email LPA a copy of parent notification letter via emai. Education Coordinator will send LPA a copy of the retest summary once completed.
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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: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris Whitmore	TELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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