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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416900
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:05:35 PM


Document Has Been Signed on 12/02/2022 03:05 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:107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD STARTFACILITY NUMBER:
197416900
ADMINISTRATOR:ALETA WILLIAMSFACILITY TYPE:
850
ADDRESS:146 EAST 107TH. STREET ROOM K4TELEPHONE:
(323) 756-8137
CITY:LOS ANGELESSTATE: CAZIP CODE:
90003
CAPACITY:22CENSUS: 11DATE:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Aleta Williams, PrincipalTIME COMPLETED:
03:15 PM
NARRATIVE
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On December 2, 2022, at 2:00 p.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection and met with Principal Aleta Williams. LPA disclosed the purpose of the inspection and was granted entry into the facility office staff.

There were 11 children and three 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 fountain in the outdoor play area near Room# 1 had a lead exceedance of 134.4 and 161.5.

At 2:10 p.m. LPA observed and tested the water sources with ALE. Water fountain in the classroom was observed to be off, outdoor waster fountain was covered with a bag, inaccessible to children. Per Principal, water is made readily available to children via water bottles provided at the facility. LPA observed water bottles on hand. There are additional water fountains and water fillers stations outdoors for children to use. Lead posting were observed on the door in the main office. LAUSD Lead exceedance team has begun to correct the ALE by shutting off the water and is in the process of installing filters to the affected water sources. LAUSD facility maintenance has not given a date to begin work. 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.

Per Principal, 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 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: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900
VISIT DATE: 12/02/2022
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 Corrections were reviewed and developed with Principal. A copy of this report and appeal rights were discussed and left with Principal, Aleta Williams, whose signature on this form confirm receipt of these documents.

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SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/02/2022 03:05 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: 107TH. STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
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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Based on record review the licensee did not ensure water sources at facility meet lead requirements. Lead test results showed that two water sources have an action level exceedance. LPA observed water sources are inaccessible to children.
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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: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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