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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012408
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:38:16 PM


Document Has Been Signed on 02/21/2024 02:38 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:PACIFIC AVENUE EDUCATION CENTERFACILITY NUMBER:
198012408
ADMINISTRATOR:YURITZY VAZQUEZFACILITY TYPE:
850
ADDRESS:440 W. LOMITA AVE.TELEPHONE:
(818) 547-0103
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY:89CENSUS: 46DATE:
02/21/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Adriana Hernandez, Program SupervisorTIME COMPLETED:
02:50 PM
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On 02/21/24, at 1:30 PM, Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management inspection for an Action Level Exceedance (ALE) detected in a water fixture in the facility. LPA met with Adriana Hernandez, Program Supervisor who guided analyst on a tour of the facility. During this inspection total of 46 children were present in the facility. LPA observed 31 children with 5 staff in room 1107, 15 children with 2 staff in room 32. Facility was within ratio & capacity. A COVID 19 risk assessment was conducted prior to entering the facility.

Analyst reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

Facility provided required forms LIC 9276, and LIC9275. Per program supervisor she will submit labeled facility sketch (LIC999) to LPA by 03/20/24.

The Department received notification from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 04/12/23. Sample Site D reported with 15.300 ppb or greater lead exceedance levels.

Sample Site D – two water faucets in Room 1107. Pictures were taken.

Per Program Supervisor two water faucets in room 1107 currently not in use and both water faucets were disconnected since Covid 19 started, 03/2020. Per Program Supervisor the facility was not using two water faucets in room 1107 even prior to the discovery of its lead level exceedance. The two water faucets was observed to be disconnected. LPA checked both water faucets in room 1107 and observed both faucets were disconnected and not working. Per Program Supervisor, they will have parts of faucets replaced and obtain a retest of it afterwards.


REPORT CONTINUES ON NEXT PAGE 1 OF 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PACIFIC AVENUE EDUCATION CENTER
FACILITY NUMBER: 198012408
VISIT DATE: 02/21/2024
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Grant funding will be available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information, including additional resources please visit https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information.

A copy of PIN 21-21-CCP and appeal rights were provided to the facility today.

The deficiency listed on the following page were 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.



The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Adriana Hernandez, Program Supervisor at 2:50 PM.


REPORT END 2 OF 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/21/2024 02:38 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: PACIFIC AVENUE EDUCATION CENTER
FACILITY NUMBER: 198012408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
HSC
1597.16(a)(1)

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DEFICIENCIES & PLANS OF CORRECTION (POCs)
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.
This requirement is not met as evidenced by:
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Per Program Supervisor two water faucets in room 1107 currently not in use and both water faucets were disconnected since Covid 19 started, 03/2020. Per Program Supervisor the facility was not using two water faucets in room 1107 even prior to the discovery of lead level exceedance.
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The facility was inspected and water samples were collected on 04/12/23. Sample Site D, two water faucets in Room 1107 were reported with 15.300 ppb or greater lead exceedance levels.
This poses a potential health, safety and personal right risk to the children in care.
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 The two water faucets were observed to be disconnected. Per Program Supervisor, they will have parts of faucets replaced and obtain a retest of it afterwards.

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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: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3