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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018831
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:01:50 PM


Document Has Been Signed on 10/11/2023 01:01 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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:PINE TREE PRESCHOOLFACILITY NUMBER:
198018831
ADMINISTRATOR:ADA CABRERA-VELASQUEZFACILITY TYPE:
850
ADDRESS:311 S. NORMANDIE AVE.TELEPHONE:
(213) 365-0909
CITY:LOS ANGELESSTATE: CAZIP CODE:
90020
CAPACITY:63CENSUS: 13DATE:
10/11/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Director Ada Cabrera VelasquezTIME COMPLETED:
01:15 PM
NARRATIVE
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On 10/11/2023, at 10:45 a.m. Licensing Program Analysts (LPAs) Veronica Martinez Garza and Suzana Safaryan conducted an unannounced case management inspection for an Action Level Exceedance (ALE) detected in a water fixture in the facility. LPAs met with facility assistant director, Mariela Velasquez Vasquez, during the visit. Director Ada Cabrera-Velasquez arrived at 12:00 p.m. and assisted LPAs with the rest of the inspection. Also present in the facility were 13-day care children and 3 teachers/staff. 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 facility sketch and required forms LIC 9276, LIC999 and LIC9275 to LPA on 10/10/23.

On 09/28/2023, 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 08/25/2023. Faucets and drinking fountain reported with 5.5 ppb or greater lead exceedance levels were as follows:

 A – Water Fountain In Facility Kitchen (5.800 UG/L) – Fountain has not been in use

Assistant director stated that the facility has not been using the water fountain located in the playground prior to March of 2020. The water fountain was terminated when the facility was informed by analyst that it was exceeding acceptable levels. Facility has put an "out of order/do not use" sign on and around the water fountain and made it further inaccessible by attaching and securing a plastic bag around the outlet.
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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3386
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831
VISIT DATE: 10/11/2023
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The facility sketch does not reflect that the kitchen faucet was tested for Lead. Director stated that the facility is using the kitchen faucet to rinse off fruit but for no other type of meal preparation. Director provided LPA with a copy of the sampling test results report where it only identifies 3 water fountains were tested and not the kitchen faucet. Director stated that she will have the water fountain replaced, obtain a retest of it afterwards and test the kitchen faucet.

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

See LIC809D for Type B deficiency cited.

Exit interview conducted and report was reviewed with the facility representative, Director Ada Cabrera-Velasquez.

A copy of PIN 21-21_1-CCP and appeal rights were provided to the facility today. A notice of site visit was also provided and must remain posted for 30 days.


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SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3386
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/11/2023 01:01 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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1) California Lead Action Level at Child Care Centers. (b) Testing results with...readings of 0.5 ppb or greater..., 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
is not met as evidenced by:
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Per Director, she will replace the faucet that had the Lead exceedance and will schedule a retest. Assistant director covered the outlet to make it inacessible to children and placed a do not use sign. LPA took pictures. Director will submit proof of retest and replacement of faucet to LPA by POC due date.
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Based on record review, the licensee did not comply with the directive above, as one outlet (water fountain located in the playground not used) out of three outlets tested with an Action Level Exceedance (ALE). This poses an immediate Health and
Safety risk to children in care.
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Type B
11/09/2023
Section Cited
HSC1597.16(a)(1)

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(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 Director, facility will not use the kitchen faucet to rinse off fruits and will schedule a lead test. Assistant director covered the kitchen faucet to make it inacessible and to avoid using it to rinse off fruit and placed a do not use sign. LPA took pictures. Director will submit proof of lead test to LPA by POC due date. Director understands that the kitchen faucet is to remain covered and not in use until lead results come back with no lead.
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Based on record review, the licensee did not comply with the section cited above in facility did not test the kitchen faucet for LEAD which poses/posed a potential health, safety or personal rights risk to persons 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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3386
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
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