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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405109
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:06:49 PM


Document Has Been Signed on 02/14/2023 02:06 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:CONGREGATION BETH SHALOMFACILITY NUMBER:
197405109
ADMINISTRATOR:CAROL BLOOMFACILITY TYPE:
850
ADDRESS:21430 CENTRE POINTE PARKWAYTELEPHONE:
(661) 254-2411
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:96CENSUS: DATE:
02/14/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Carol BloomTIME COMPLETED:
02:10 PM
NARRATIVE
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On 2/14/2023 Licensing Program Analyst (LPA) Isabel Ortega conducted an unannounced case management inspection. LPA Ortega met with Director Carol Bloom and toured the facility according to the facility sketch. The purpose of today's inspection is to conduct a case management inspection regarding lead exceedance referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at the facility.

Palmdale Regional Office received notification of water lead exceedance at the facility resulting from a recent sample tested on 12/30/2022. The water lead sampling test results are based on the records reviewed (A) kitchen faucet with results of an ALE of 14.0 ppb, kitchen faucet (B) with an ALE of 320.0 ppb and (B30) Kitchen faucet with ALE of 11.0 ppb. These three areas identified are exceeding the ALE water of 5.5 ppb.

According to facility all three kitchen faucets are not currently being utilized by the facility. Facility has placed the water faucets(A), (B) and (B30) out of service. Facility has replaced the faucets and vales on 1/27/2023. Facility is pending an appointment to test water again on identified areas (A), (B) and (B30) (see plan of correction). Filtered portable water is readily available to children during hours of operation. A filtered water dispenser was observed in the kitchen, facility will utilize filtered water dispenser for all food preparation until results are under 5.5ppb (see plan of correction for further corrective action 809D).
SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109
VISIT DATE: 02/14/2023
NARRATIVE
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The facility has posted a notification for authorized representatives (parents, legal guardians, ect.) regarding water sample results ALE and corrective action plan in writing visible to parents and or representatives.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, Written Directives PIN 21-21-CCP Section 101703(a): a type B deficiency is being cited (see next page, 809 D).

An exit interview was provided, facility was provided with a copy of this report, appeal rights and notice of site visit (NOA).

This report shall be made available to the public upon request. The Notice of Site Visit (NOA) is required to be posted for 30 days.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2023 02:06 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: CONGREGATION BETH SHALOM
FACILITY NUMBER: 197405109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2023
Section Cited

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101700.3 California Lead Action Level at Child Care Centers (a) California’s Action Level for lead in water at Child Care Centers is 5 ppb. (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 Exceedance. (c) If testing indicates an Action Level Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response pursuant to section 101704 shall be required.

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Facility has replaced the water vales and the water faucets on identified areas A, B and B30 on 1/27/2023. Facility has also shut off the water vales in the kitchen and posted a Out of service sign. During inspection facility posted parent notification regarding lead in the kitchen utilized for food preparation(rinsing fruits and vegetables). Facility will make an appointment to retest the water in the kitchen A, B, and B30 and until ALE is less than 5.5ppb use alternative water for food preparation.
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This requirement was not met by evidence base on ALE results containing lead in kitchen faucets, (A) ALE of 14 ppb, (B) containing an ALE of 320ppb and (B30) with ALE of 14ppb which is out of compliance exceeding the allowable ALE of 5.5 ppb. This poses a potential health and safety risk to the 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: Lady KingTELEPHONE: (310) 568-1824
LICENSING EVALUATOR NAME: Isabel OrtegaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
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