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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197410448
Report Date: 12/14/2022
Date Signed: 12/14/2022 10:28:44 AM


Document Has Been Signed on 12/14/2022 10:28 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 DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG.FACILITY NUMBER:
197410448
ADMINISTRATOR:MARIA PATRICE WINNFACILITY TYPE:
830
ADDRESS:320 NO. CHARLES E. YOUNG DR.TELEPHONE:
3102060633
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY:20CENSUS: 0DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Maria Patrice Winnm Director TIME COMPLETED:
10:35 AM
NARRATIVE
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On 12/14/2022, 8:25am Licensing Program Analyst (LPA) Denise Miranda arrived at UCLA Dept. of Psychology Fernald Infant Dev. Prog. to conduct an unannounced case management visit. LPA Miranda was met by Director Center Maria Patrice Winn. LPA Miranda 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 water outlets 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 11/15/2022, Director Maria Patrice Winn provided LPA with a copy of the results of lead water sample testing conducted by Weck Laboratories, Inc. Testing was conducted on 10/20/2022 and results were received on 10/31/2022. Per the report, the following water outlets yielded the following results:

1.) Water Outlet “I” (Kitchen faucet, located inside of the classroom Blue room); 9.2 pbb

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 5


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 DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG.
FACILITY NUMBER: 197410448
VISIT DATE: 12/14/2022
NARRATIVE
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2.) Water Outlet “I30” (Kitchen faucet, located inside of the classroom Blue room); 7.2 pbb

3.) Water Outlet “D” (outdoor area, sink); 5.9 pbb.

During today’s visit LPA Miranda conducted a tour of the facility and observed water outlets identified on facility sketch, however, Director agreed that sketch needs to be revised showing the water outlet codes, per sketch only shows the two locations that had lead exceedance results. LPA took photos of the water outlets and observed Water Outlets “I”, “I30 (same location) and “D” were taped :“do not use” Center Director verified that children and staff do not have access to the water outlets that have been identified showing elevated lead levels. The water outlets were immediately decommissioned and tagged for further action by the UCLA Facilities Team.

Per Director, Facility made the replacement of the localized fixtures and the facility will provide a writing declaration with their plan of correction no later than 12/16/2022.

Per director, Facility is using the fountain location at the outdoor space and the kitchen area, facility are using the lounge room, located inside of the classroom blue room. Facility is using the lounge room faucet for food preparation and drink water. Per Director, they filled out a portable filter (Britta) for drink water.

LPA Miranda 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.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG.
FACILITY NUMBER: 197410448
VISIT DATE: 12/14/2022
NARRATIVE
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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 10/20/2022 revealed that levels of lead were beyond the allowable amount deemed by the State of California. Water Outlets “I”, “I30” and “D” have Action Lead Exceedance (ALE) levels of pbb “I” 9.2 pbb, “I30” 7.2 and “D” 5.9 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. 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.

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.

For more information, go to the California Childhood. Lead Poisoning Prevention

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG.
FACILITY NUMBER: 197410448
VISIT DATE: 12/14/2022
NARRATIVE
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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 Maria Patrice Winn.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/14/2022 10:28 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 DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG.
FACILITY NUMBER: 197410448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
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.
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The water outlet (I, I30 and D), were immediately decommissioned and tapped “Do not use”. Per Director, replacement of the location fixture has been replaced. Director agreed to submit a written declaration of plan of correction, along with the date of the retesting, revised sketch showing all codes and locations, revised LIC9276 form showing the correct name of the designated person that
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This requirement is not met as evidenced by: Lead water testing samples taken on 10/20/2022 revealed that levels of lead were beyond the allowable amount deemed by the State of California. Water Outlets “I” ,“I30” and “D” have Action Lead Exceedance (ALE) “I” 9.2pbb, “I30”7.2 pbb and “D” 5.9pbb. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care.
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accompany the Sample at all times while they are present at Child Care Center and sign by Representative and the Water Sampler. This plan of correction will be sent to LPA Miranda via email no later than 12/16/2022.

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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: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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