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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415232
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:42:34 AM

Document Has Been Signed on 12/15/2022 11:42 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:THERESA HUGHES ELEMENTARY SCHOOLFACILITY NUMBER:
197415232
ADMINISTRATOR:ADRIANA CORTEZFACILITY TYPE:
850
ADDRESS:4242 CLARA STREET, K-4TELEPHONE:
(323) 560-4422
CITY:CUDAHYSTATE: CAZIP CODE:
90201
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
12/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Adriana Cortez, PrincipalTIME COMPLETED:
11:45 AM
NARRATIVE
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On December 15, 2022, at 9:45 a.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection and met with Principal Adriana Cortez. LPA disclosed the purpose of the inspection and was granted entry into the facility staff.

There were no children and two staff present during the inspection. Classroom was in transition from AM to PM program.

The purpose of today's inspection was to discuss the water lead test results. Results show that one water source has action level exceedance (ALE) of lead. The drinking fountain located inside the classroom has a lead exceedance of 7.8 Points Per Billion (ppb).

At 10:15 a.m. LPA observed and tested of the water source with ALE. Water source were observed to be inaccessible to children. The drinking fountains indoors has a bag placed over it. Per Staff, families are asked to bring water bottles from home for the children, staff purchase water bottles or parents donate them. LPA observed water bottles stored in the cabinet. LPA discussed with Principal that water should be provided by the facility both indoors and outdoors. LAUSD Lead exceedance team has begun to correct the ALE and is in the process of installing filters to the affected water sourced. LAUSD facility maintenance has not given a date to begin work. 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.

All meals are prepackaged and delivered daily by Los Angeles Unified School District (LAUSD). Food is not cook or prepared at the facility.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with ----------------------PAGE
Trevino Cochran
Denise Gibbs
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: THERESA HUGHES ELEMENTARY SCHOOL
FACILITY NUMBER: 197415232
VISIT DATE: 12/15/2022
NARRATIVE
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California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that is being cited needs to be cleared to protect the children’s health & safety.

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

Exit interview was conducted and Plans of Corrections were reviewed and developed with Principal. A copy of this report and appeal rights were discussed and left with Principal, Adriana Cortez, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2022 11:42 AM - It Cannot Be Edited


Created By: Denise Gibbs On 12/15/2022 at 11:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: THERESA HUGHES ELEMENTARY SCHOOL
FACILITY NUMBER: 197415232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2023
Section Cited

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101700.3(b)(1)
(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.
This requirement was not met as evidence by:
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Based on record review the licensee did not ensure water source at facility meet lead requirements. Lead test results showed that one drinking water sources has an action level exceedance. LPA observed water source is inaccessible to children. This poses a potential Health, Safety or 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:Trevino Cochran
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022


LIC809 (FAS) - (06/04)
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