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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416691
Report Date: 01/15/2025
Date Signed: 01/15/2025 01:52:56 PM

Document Has Been Signed on 01/15/2025 01:52 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:BROAD AVENUE ELEMENTARY SCHOOL CSPPFACILITY NUMBER:
197416691
ADMINISTRATOR/
DIRECTOR:		EVER-ALLEN, DEBORAHFACILITY TYPE:
850
ADDRESS:24815 BROAD AVENUE RM.13TELEPHONE:
(310) 835-3118
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 10DATE:
01/15/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Xochitl Vazquez, PrincipalTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced case management inspection on 01/07/2025 for the purpose of addressing an Action Lead Exceedance (ALE) at the facility. LPA arrived to the facility at 12:20PM and met with Elizabeth Diaz, Teacher who guided LPA on a tour of the facility. Upon arriving to Room 13, LPA observed 10 children and 1 staff present. LPA was later met by Xochitl Vazquez, Principal.

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.

Community Care Licensing was notified of the results of the Lead Water Testing conducted at the facility on 11/03/2022. The sample testing was for Outlet "A" with results above 5.5 ppb which is considered an exceedance. Outlet "A" was reported to have an exceedance of 209ppb. LPA was not able to verify which outlets were tested because a facility sketch was not provided to the Department prior or during the inspection.

Per Teacher, the indoor drinking outlet is not operable. LPA was able to verify that in fact the indoor outlet for drinking water is not in service and no water is available. Per Teacher, children bring a reusable water bottle to care daily and facility is provided drinking water through parent donations.

LPA advised Principal that the following documents pending are as followed:
  • Completed External Water Sampler Self-Certification Form (LIC 9275)
  • Completed Child Care Center Sampling Checklist Form (LIC 9276)
  • Facility Sketch identifying the location of water outlet/s used for drinking
  • A copy of the initial water testing results for outlets tested
  • Proof of corrections for Outlet "A"
  • A copy of water retesting results summary for Outlets "A"

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Rita RamosTELEPHONE: (424) 301-3061
Lilia HernandezTELEPHONE: 424-301-3071
DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BROAD AVENUE ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416691
VISIT DATE: 01/15/2025
NARRATIVE
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Principal was advised to posted lead testing results, in a location consistent with the requirements of subsection (b) of section 1596.8595 of the Health & Safety Code, for parents and families to view at the facility within 24-hours of receiving the results from the Department. Facility will notify all parents or guardians of children in care of lead exceedance results and what has been done to date and remediation plan for water outlet “A”.

Based on interviews and results reported to the Department, it has been determined that BROAD AVENUE ELEMENTARY SCHOOL CSPP 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. 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.

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

Exit interview conducted and report was reviewed with Xochitl Vazquez, Principal.

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SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Lilia HernandezTELEPHONE: 424-301-3071
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/15/2025 01:52 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: BROAD AVENUE ELEMENTARY SCHOOL CSPP
FACILITY NUMBER: 197416691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(b) Testing results with fractional ppb readings of 0.5 ppb or greater...(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:
Deficient Practice Statement
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POC Due Date: 01/31/2025
Plan of Correction
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Per Principal, the following documents will be submitted to LPA via email by POC due date: Completed External Water Sampler Self-Certification Form (LIC 9275), Completed Child Care Center Sampling Checklist Form (LIC 9276),Facility Sketch identifying the location of water outlet/s used for drinking,
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Rita RamosTELEPHONE: (424) 301-3061
Lilia HernandezTELEPHONE: 424-301-3071

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025

LIC809 (FAS) - (06/04)
Page: 3 of 3