<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015619
Report Date: 01/11/2024
Date Signed: 01/11/2024 10:26:16 AM


Document Has Been Signed on 01/11/2024 10:26 AM - 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:NORWALK-LA MIRADA USD HEAD START/STATE PS-CHAVEZFACILITY NUMBER:
198015619
ADMINISTRATOR:JACQUELINE FLIETESFACILITY TYPE:
850
ADDRESS:12110 E. WALNUT AVENUETELEPHONE:
(562) 210-4533
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:48CENSUS: 25DATE:
01/11/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Loretta GallegosTIME COMPLETED:
10:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/11/24, about 8:45AM, Licensing Program Analyst (LPA) T. Tran conducted an unannounced case management inspection at Norwalk-La Mirada USD HS-Chavez.. Upon arrival, LPA met with Loretta Gallegos, Assistant Director and we toured the facility. LPA observed proper care and supervision and ratio.

The purpose of today's inspection was to go over the water lead test results received on 12/07/22. Results show three water sources had action level exceedance of lead. The classroom bubblers in rooms 42 & 43 as well the the bubbler in the children's playground had a lead result 6.0 or greater. LPA observed that listed bubblers had been covered and made inaccessible to children in care. LPA spoke with facility representative, in the meantime, facility have filtered water faucets in the classrooms for staff to refill in the igloo thermal with disposable cups for children to use indoor and outdoor. A deficiency was cited to ensure that the water faucets 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 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. Plan of Correction has been 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, Loretta Gallegos.

SUPERVISOR'S NAME: Denise GibbsTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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 01/11/2024 10:26 AM - 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: NORWALK-LA MIRADA USD HEAD START/STATE PS-CHAVEZ
FACILITY NUMBER: 198015619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
101700.3(b)(1)–(b)

1
2
3
4
5
6
7
Result with values of 5.5 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.
1
2
3
4
5
6
7
On 12/07/22, facility had provided a written statement on their plan to continue to ensure that the water sources will not be used as a drinking or food preparation source. POC is cleared during today's visit.
8
9
10
11
12
13
14
LPA observed water bubblers was disconnected to be made inaccessible to children in care. This is a potential risk to the health and safety of the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2