191500903-1-20-2023-33-CC-MJAA-CN9NRB-20230120094113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500903
Report Date: 01/20/2023
Date Signed: 01/20/2023 09:41:24 AM

Document Has Been Signed on 01/20/2023 09:41 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	CLAIRBOURN SCHOOL		FACILITY NUMBER:	191500903
ADMINISTRATOR:	KAREN D. PACIOREK		FACILITY TYPE:	850
ADDRESS:	8400 HUNTINGTON DR		TELEPHONE:	(626) 286-3108
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	64	CENSUS: 15	DATE:	01/20/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Karen Paciorek,		TIME COMPLETED:	10:00 AM

NARRATIVE

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On 01/20/2023, at 8:10 AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection for an Action Level Exceedance (ALE) detected in a water fixture in the facility. LPA met with facility director, Karen Paciorek who guided LPA on a tour of the facility. Also present in the facility were 15 day care children and 4 staff. Facility was within ratio & capacity. A COVID 19 risk assessment was conducted prior to entering the facility.

Analyst reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

Facility provided facility sketch and required forms LIC 9276, LIC999 and LIC9275 to LPA on 01/20/23.

On 09/26/2022, the Department received notification from the State Water Resources Control Board

(SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 09/02/2022. Faucets and drinking fountain reported with 5.5 ppb or greater lead exceedance levels were as follows:

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica Ayala	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CLAIRBOURN SCHOOL	FACILITY NUMBER: 191500903
	VISIT DATE: 01/20/2023

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C- Drinking Fountain (5.720 UG/L) - Not in use, water shut off
E- Drinking Fountain (8.310 UG/L) - Not in use, water shut off
G- Drinking Fountain (8.060 UG/L) - Not in use, water shut off
I- Sink/Drinking Fountain Outside (29.900 UG/L) - Not in use, water shut off
J- Sink/Drinking Fountain Outside (9.830 UG/L) - Not in use, water shut off
K- Sink/Drinking Fountain Outside (12.400 UG/L) - Not in use, water shut off

Director stated that the facility faucets have not been in use since COVID-19 pandemic, 2020. Facility had the water shut off since 2020 and turned the water back on for lead testing. The facility has shut the water leading to the above faucets off. Per director, an order for water filters has been placed and all faucets will be replaced and retested.

Grant funding will be available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information, including additional resources please visit

https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information

See LIC809D for Type B deficiency cited.

An exit interview was conducted and a copy of this report was provided to director, Karen Paciorek along with Notice of Site Visit. A copy of PIN 21-21-CCP was provided along with Appeal Rights.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica Ayala	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/20/2023 09:41 AM - 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CLAIRBOURN SCHOOL	FACILITY NUMBER: 191500903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/20/2023 Section Cited	1 2 3 4 5 6 7	101700.3(b)(1) California Lead Action Level at Child Care Centers. (b) Testing results with...readings of 0.5 ppb or greater..., before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Director stated that the facuets have not been in use since 2020 and the water leading to these have were shut off. Director stated that the faucets have again been shut off once lead testing was complete. Director stated filters have been bought to place in the faucets and will retest the faucets.
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the directive above, as six outlet (not in use) out of eighteen outlets tested with an Action Level Exceedance (ALE). This poses an immediate Health and Safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Monique Jessica Ayala	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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