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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416587
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:22:25 PM


Document Has Been Signed on 12/15/2022 01:22 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:SAN MIGUEL ELEMENTARY SCHOOL CSPPFACILITY NUMBER:
197416587
ADMINISTRATOR:SUSANNE FISHERFACILITY TYPE:
850
ADDRESS:9801 SAN MIGUEL AVENUETELEPHONE:
(323) 567-0511
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY:24CENSUS: 12DATE:
12/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Susanna Fisher, PrincipalTIME COMPLETED:
01:30 PM
NARRATIVE
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On December 15, 2022, at 11:50 a.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection and met with Principal Susanne Fisher. LPA disclosed the purpose of the inspection and was granted entry into the facility by facility staff.

There were 12 children and two staff present during the inspection.

The purpose of today's inspection was to discuss the water lead test results. Results show that two water sources have action level exceedance (ALE) of lead. The drinking fountain located inside the classroom and the drinking fountains located outside in the outdoor play space had a lead exceedance of 230 points per billion (ppb) and 43ppb, 9ppb.

At 12:00 p.m. LPA observed and tested the water sources with ALE. Water to the sources with ALE were observed to be off. Per classroom staff filters were added to water sources. Due to COIVD-19 precautions, children have not been using water fountains. Children bring water bottles from home and facility provides water bottles. LPA observed water bottles on hand. LPA received email from Los Angeles Unified School District (LAUSD) lead exceedance team prior to today's inspection with notification of completed corrections. Filters and tubing were added to affected water sources. Lead Exceedance Team provided LPA with retest results showing levels all under 1ppb for identified sources. LPA informed Principal that both initial and retest lead results must be posted where they can be seen by parents. A deficiency was cited to ensure that the water faucets with the exceedance will not be used as a drinking source or food preparation source for the children.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with 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. -------------------PAGE 1
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
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
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 3


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: SAN MIGUEL ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416587
VISIT DATE: 12/15/2022
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days.

Exit interview was conducted and Plans of Correction was reviewed and developed with Principal. A copy of this report and appeal rights were discussed and left with Principal, Susanne Fisher, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
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)
Page: 2 of 3
Document Has Been Signed on 12/15/2022 01:22 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: SAN MIGUEL ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
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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Water sources identified with ALE were corrected prior to inspection. LPA observed new faucets and filters added to water sources. LPA received confirmation email that Tubing and filters have been replaced along with completed, LIC 9276 Follow-Up checklist for Water Sampling During a Corrective Plan. Principal provided retest
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Based on record review the licensee did not ensure water sources at facility meet lead requirements. Lead test results showed that three water sources have an action level exceedance. This poses a potential Health, Safety or Personal Rights risk to children in care.
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results showing water source levels all under 1ppb.

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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 CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
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)
Page: 3 of 3