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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418048
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:37:19 PM


Document Has Been Signed on 03/21/2024 03:37 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:CII/WESTERN HEAD START STATE PRESCHOOLFACILITY NUMBER:
197418048
ADMINISTRATOR:MARGARITA PARRAFACILITY TYPE:
850
ADDRESS:4277 S. WESTERN AVENUETELEPHONE:
(213) 252-4380
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY:32CENSUS: 26DATE:
03/21/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Brenda JuarezTIME COMPLETED:
03:50 PM
NARRATIVE
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On 03/21/2024, about 2:15PM, Licensing Program Analysts (LPAs) T. Tran and A. Wallin conducted an unannounced case management/Lead inspection at CII Western Head Start. Upon arrival, LPAs met with Site Supervisor, Brenda Juarez and we toured the facility. LPAs observed proper care and supervision.

The purpose of today's inspection was to go over the water lead test results received on 10/07/22. Results show that three water sources had action level exceedance of lead. The toddler and preschool's restroom sinks had lead exceedance result of at least 6.5 ppb and greater. Per facility representative, those three sources only use for children's hand washing. Children drinking water was provided by sparkling water delivered to the site weekly. The area with lead levels action were removed from service and rested on 4/12/23. A deficiency was cited to ensure that the water sources noted will not be used as a drinking source or food preparation source for the children.

The deficiency listed on the following page were observed by the LPAs 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. Record review indicated last retesting completed on 4/12/23. Citation was cleared during today's visit.

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

Exit interview conducted and report was reviewed with the facility representative, Brenda Juarez.

SUPERVISOR'S NAME: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 2


Document Has Been Signed on 03/21/2024 03:37 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CII/WESTERN HEAD START STATE PRESCHOOL
FACILITY NUMBER: 197418048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2024
Section Cited
CCR
101700.3(b)(1)-(b)

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Result with values of 5.0 ppb or greater shall be deemed an Action Level Exceedance This requirement was not met as evidence by record review. Lead test results showed that three water sources had an action level exceedance.
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Facility had provided correction record completed on 4/12/23 all water outlet had been removed. Facility provide filtered water for the children to drink.
POC cleared during today's visit.
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LPA observed all three outlets had been removed.This is a potential risk to the health and safety of the 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: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2