197410448-4-10-2023-58-CC-SORS-CQRQ2Q-20230410114731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197410448
Report Date: 04/10/2023
Date Signed: 04/10/2023 11:47:41 AM

Document Has Been Signed on 04/10/2023 11:47 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 WINN		FACILITY TYPE:	830
ADDRESS:	320 NO. CHARLES E. YOUNG DR.		TELEPHONE:	(310) 206-0633
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90095
CAPACITY:	20	CENSUS: 16	DATE:	04/10/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Lead Teacher/Assistant DIrector - Courtney Kumar		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/10/2023, Licensing Program Analyst (LPA) Suzette Ornelas arrived at UCLA DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG. to conduct an unannounced case management visit. LPA Ornelas was met by Assistant DIrector - Courtney Kumar. LPA informed Assistant Director about the purpose of the visit and was guided on a tour of the facility. LPA observed 16 children and 11 adults during today’s visit. 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 ppb, or greater. The purpose of today’s visit is to ensure that faucets are not in use and there is potable source of water for children and staff at the facility. On 04/05/2023, LPA Ornelas contacted the facility; however, call went to voicemail and LPA was unable to obtain the following documents from director via email: External Water Sample Self-Certification Form (LIC 9275), Signed and dated Child Care Center Sampling Checklist Form (LIC 9276), and Facility Sketch (fully labeled with locations of all water outlets). LPA contacted LPA Denise Miranda who provided LPA Ornelas with copies of the required documents. Per the retest report conducted on 2/14/2023, the following water outlet yielded the following results: 1.) Faucet G - Outdoor Play Area (Blue Room Yard - Adult Sink): 6.0 ppb During today’s visit LPA Ornelas conducted a tour of the facility and observed 1 water outlet/outdoor adult sink that was made inaccessible by the use of red tape. Not used for food prep or consumption. LPA obtained photo of the water outlet that was identified on the facility sketch. Assistant Director stated that the children do not consume water from the water outlet. Per assistant director, purified Brita filtered drinking water is provided and accessible to children in care. LPA observed Brita filtered water in the classrooms.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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
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: 04/10/2023

NARRATIVE

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Based on observation, interviews and supportive documents it has been determined that UCLA DEPT. OF PSYCHOLOGY FERNALD INFANT DEV.PROG 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 sample re taken on 02/14/2023 revealed that levels of lead were beyond allowable amount deemed by the State of California.

LPA discussed Proof of Correction (POC). Assistant Director stated fixture has been replaced and retested; however, due to retest showing a lead exceedance once again, a Risk Assessment is taking to place to determine whether the fixture will be replaced or removed. Once a plan is set in place, LPA will be notified via email.

As mentioned earlier, Director submitted all required licensing forms, supportive documents and provided LPA with a Plan of Correction Date of 07/01/2023.

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.

Exit interview conducted. A copy of this report, and Notice of Site Visit provided to Assistant Director.

suzette.ornelas@dss.ca.gov

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

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