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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600943
Report Date: 01/24/2023
Date Signed: 01/24/2023 09:44:32 AM


Document Has Been Signed on 01/24/2023 09:44 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:BETHANY LUTHERAN CHURCH PRESCHOOLFACILITY NUMBER:
191600943
ADMINISTRATOR:TAMARA SIMPSONFACILITY TYPE:
850
ADDRESS:4644 CLARK AVETELEPHONE:
(562) 429-7335
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:81CENSUS: 67DATE:
01/24/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Tamara SimpsonTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced case management Lead Testing exceedance inspection on January 24, 2023. LPA Birks met with Director Tamara Simpson who guided LPA on a tour of the facility. There were 67 children and 10 staff present during the inspection.

The purpose of today's inspection is to review and discuss the December 10, 2022 water lead test results received on January 13, 2023. The results indicate that one water source had action level exceedance of lead. The water faucet in classroom 124 had a lead result of 7.8. Director Simpson informed LPA Birks that the fountain was shut off during covid. She also indicated that the plumbing fixture was replaced and the water fountain capped. The faucet needs to be flushed and facility keeps the faucet covered with plastic so it is inaccessible to staff and children. Director Simpson indicated the room uses water from other sources in the facility (which were tested and have passing water levels).

At approximately 8:55am LPA Birks took pictures of the water faucet and capped fountain. A deficiency was cited to ensure that the water fixture noted will not be used as a drinking source or food preparation source for children.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency being cited needs to be cleared to protect the children’s health & safety. Director Simpson exhibited to LPA that the water source is not in use and submitted a written plan of correction during todays visit. Therefore, the citation is cleared.

The Notice of Site Visit (LIC 9213 –must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview conducted with Director Tamara Simpson and a copy of Appeal Rights (LIC 9058) was discussed.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
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 01/24/2023 09:44 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: BETHANY LUTHERAN CHURCH PRESCHOOL
FACILITY NUMBER: 191600943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2023
Section Cited

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(b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level.

(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedence
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Director submitted plan of correction regarding repairs, faucit is covered in plastic and not in use. Water fountain capped.

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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: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
LIC809 (FAS) - (06/04)
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