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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597486
Report Date: 04/10/2023
Date Signed: 04/10/2023 10:50:13 AM


Document Has Been Signed on 04/10/2023 10:50 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:MADISON/CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191597486
ADMINISTRATOR:KYM ALLENFACILITY TYPE:
850
ADDRESS:1351 S. MAIN STREETTELEPHONE:
(909) 622-9805
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY:96CENSUS: 37DATE:
04/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Andrew Payne TIME COMPLETED:
11:10 AM
NARRATIVE
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On 04/10/2023, at 10:20 AM, Licensing Program Analyst (LPA) Judy Mora conducted an unannounced case management inspection for an Action Level Exceedance (ALE) detected in a water fixture in the facility. LPA met with Andrew Payne, Maintenance Technician, for this inspection. Also present in the facility were 37 day care children and 09 teachers/staff. Facility was within ratio & capacity.

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 program facilitator 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 LIC 9275 to LPA on 04/10/2023. On 03/31/2023, 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 03/16/2023. Sink Faucet reported with 5.5 ppb or greater lead exceedance levels were as follows:

• Sink Faucet Fixture L in Room HS 2 (8.4 UG/L) – Faucet was replaced and re-tested. Pictures were taken.

At approximately 10:28 AM, LPA observed that Room HS 2 is not currently being used by children. LPA observed that the sink is not labeled or taped off. Facilities Planner indicated that the sink is only used for hand washing and not drinking water. Water pitchers and disposable cups are used for drinking water. The use of the faucet was terminated when the facility was informed by the analyst that it was exceeding acceptable levels. The faucet in the classroom has been replaced and re-tested. The facility has not received the results as of this date.

*REPORT CONTINUES ON NEXT PAGE
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
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: MADISON/CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191597486
VISIT DATE: 04/10/2023
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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 in accordance with California Code od Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

A copy of PIN 21-21-CCP and appeal rights were provided to facility today.

A notice of site visit was also provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Andrew Payne.


*END OF REPORT
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/10/2023 10:50 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: MADISON/CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191597486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited

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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
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Facilities Planner stated the fixture was replaced and they did the retesting. They are currently waiting for the results. LPA will be
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as evidenced by Based on record review, the licensee did not comply with the directive above, as one outlet tested with an Action Level Exceedance (ALE). This poses a potential health and safety risk to children 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 896-6847
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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