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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601954
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:25:17 AM


Document Has Been Signed on 10/27/2022 11:25 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:UCLA EARLY CARE AND EDUCATION-INFANTSFACILITY NUMBER:
191601954
ADMINISTRATOR:AMY AGNEWFACILITY TYPE:
830
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
(310) 825-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY:60CENSUS: 29DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Center Coordinator Rosie CastilloTIME COMPLETED:
10:45 AM
NARRATIVE
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On 10/27/2022, Licensing Program Analyst (LPA) Sabrina Martinez arrived at UCLA Early Care and Education - Infants to conduct an unannounced case management visit. LPA Martinez was met by Center Coordinator Rosie Castillo and Director of Operations Marcia Martinez. LPA Martinez informed facility staff about the purpose of the visit and was guided on a tour of the facility.

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 1 water outlet 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 10/05/2022, Director Amy Agnew provided LPA Martinez with a copy of the results of lead water sample testing conducted by Weck Laboratories, Inc. Testing was conducted on 09/22/2022 and results were received on 10/04/2022. Per the report, the following water outlet yielded the following result:

1.) Water Outlet “I” (Hose spigot in the sand play area in the infant yard): 8.3 pbb

During today’s visit LPA Martinez conducted a tour of the facility and observed water outlet identified on facility sketch. LPA observed Water Outlet “I” was bagged and taped. LPA took photos of the water outlet.

Center Coordinator and Director of Operations verified that children and staff do not have access to the water outlets that have been identified showing elevated lead levels. The water outlet was immediately decommissioned and tagged for further action by the UCLA Facilities Team. UCLA Facilities will install replacement of the localized fixture to include the angle stops and supply lines and replace the hose bib. Testing will be done again once the work is completed.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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 4


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: UCLA EARLY CARE AND EDUCATION-INFANTS
FACILITY NUMBER: 191601954
VISIT DATE: 10/27/2022
NARRATIVE
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Facility staff stated that since reopening March 16, 2020, facility utilized only the Arrowhead Filter Water. Outlets used for food preparation were not observed to have an Action Lead Exceedance (ALE) of 5.5 ppb or over.

During today’s inspection, LPA Martinez obtained the following documents: External Water Sampler 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.

Based on observation, interviews, and supportive documents it has been determined that the facility has 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 09/22/2022 revealed that levels of lead were beyond the allowable amount deemed by the State of California. Water Outlets “I” has Action Lead Exceedance (ALE) level of 8.3 pbb.

This facility is being cited (1) deficiency during today’s visit. 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 Center Coordinator who stated that water outlets identified with an Action Lead Exceedance of 5.5 ppb or over have been inoperable while the campus goes through the process of retesting the water outlets. These outlets will not be accessible for use until a retest has occurred. LPA Martinez observed signs posted stating Out of Service. A notification of letter was sent out to parents with notification of cease of water outlets and remediation for plan for water outlets or alternative. Facility will send LPA a copy of the re-test summary once completed on or before 11/28/2022.

Instructions for required lead testing are outlined in PIN 21-21. This PIN which contains Written Directives, have the same force and effects as the regulations contained in Title 22 of the California Code of Regulations.

Child Care Centers are expected to use an Environmental Laboratory Accreditation Program (ELAP), for lead testing. Accreditation from the California Environmental Laboratory Accreditation Program, known as an ELAP laboratory, is equipped to measure the amount of lead in a parts per billion (ppb) unit of measurement.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/27/2022 11:25 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: UCLA EARLY CARE AND EDUCATION-INFANTS
FACILITY NUMBER: 191601954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited

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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 09/22/2022 revealed that levels of lead
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were beyond the allowable amount deemed by the State of California. Water Outlet “I” has Action Lead Exceedance (ALE) level of 8.3 pbb.

This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care.
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A copy of the re-test summary report will be emailed to LPA Martinez on or before Monday, 11/28/2022.

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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: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: UCLA EARLY CARE AND EDUCATION-INFANTS
FACILITY NUMBER: 191601954
VISIT DATE: 10/27/2022
NARRATIVE
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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.

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.

A copy of this Report (LIC809 & LIC809D), Appeal Rights (LIC9058) and Notice of Site Visit (LIC9213) were reviewed and provided to Center Coordinator Rosie Castillo.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Sabrina MartinezTELEPHONE: (424) 301-3059
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4