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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191802294
Report Date: 03/06/2024
Date Signed: 03/06/2024 06:07:59 PM


Document Has Been Signed on 03/06/2024 06:07 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:LUMBINI CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191802294
ADMINISTRATOR:NICHO, LESLIEFACILITY TYPE:
850
ADDRESS:505 EAST THIRD STREETTELEPHONE:
(213) 680-2976
CITY:LOS ANGELESSTATE: CAZIP CODE:
90013
CAPACITY:60CENSUS: 12DATE:
03/06/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
05:20 PM
MET WITH:Leslie Nicho, Facility Representative (FR)TIME COMPLETED:
06:30 PM
NARRATIVE
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On 03/06/2024 at 4:00 PM, Licensing Program Analysts (LPAs) Katrina Chicote and Claudia Kam conducted an Unannounced Case Management Inspection and met with Facility Representative (FR) Leslie Nicho, Director. LPAs disclosed the purpose of the inspection and was granted entry into the facility and was provided guided tour. Census was taken.

The purpose of today's inspection was to discuss the water lead test results. Results received by RO indicated a water source, labeled H, to have action level exceedance (ALE) of lead with results of 18 ppb. LPA Claudia Kam notified FR of results who stated that she was aware of results but the classroom where water source is is currently not being used at this time.

LPAs observed and took pictures of water source which is in Orange Room to be bubbler. LPAs tested water bubbler and observed to be operational at time of inspection. Per FR, Orange Room is currently not being used by children and staff as a classroom though LPAs observed children have access to Orange Room as children use cubbies inside room to store their belongings. LPAs observed FR make water bubbler to be made off limits at time of inspection with duct tape and plastic covering. LPAs observed children use personal water bottles and FR states that water bottles are refilled with bottled waters or with filtered water station water. LPAs observed plastic water bottles through out facility and filtered water station at time of inspection. Per FR, they will have water retested and provide results to LPA once received. LPAs discussed posting requirements in regards to lead results with FR.

A deficiency was cited to ensure that the water sources with the exceedance will not be used as a drinking source or food preparation source for the children.

A notice of site visit was given and must remain posted for 30 days.

Exit interview was conducted and report was reviewed with Facility Representative, Leslie Nicho.
Report Ends - Page 1 of 1
SUPERVISOR'S NAME: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 2


Document Has Been Signed on 03/06/2024 06:07 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: LUMBINI CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191802294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2024
Section Cited
HSC
101700.3(b)(1)

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101700.3(b)(1)
(b) Testing results with fractional ppb readings of 5.5 ppb or greater ..., before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be... Action Level Exceedance. This requirement was not met as evidence by:
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FR states that they are working with Licensee to remediate and retest water source with ALE and once remediated will provide results to LPA. FR states children do not use water bubbler in Orange Room and use personal water bottles which is refilled with bottled water.
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Based on record review the Licensee did not ensure water source at facility to meet lead requirements. Lead test results received showed that one water source has an action level exceedance of 18 ppb. This poses a potential health, safety, and personal rights 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: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Katrina ChicoteTELEPHONE: (323) 629-7658
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2