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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019444
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:56:40 PM


Document Has Been Signed on 12/14/2022 12:56 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:ANNALEE AVE ELEMENTARY PRESCHOOLFACILITY NUMBER:
198019444
ADMINISTRATOR:EMILY BARBEEFACILITY TYPE:
850
ADDRESS:19410 ANNALEE AVETELEPHONE:
(310) 537-4740
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:22CENSUS: 11DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Christine Thomas, Assistant PrincipalTIME COMPLETED:
12:15 PM
NARRATIVE
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On December 14, 2022, at 10:40 a.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection and met with Assistant Principal (AP), Christine Thomas. LPA disclosed the purpose of the inspection and was granted entry into the facility staff.

The purpose of today's inspection was to discuss the water lead test results. Results show that one water source has action level exceedance (ALE) of lead. The drinking fountain located outside of Room#K-3 had a lead exceedance of 6.8 Points Per Billion (ppb).

At 10:50 a.m. LPA observed and tested the water source with ALE. Water source was operable. LPA received email from Los Angeles Unified School District (LAUSD) lead exceedance team prior to today's inspection with notification of completed corrections. Filters and tubing were added to affected water source. LPA informed AP that both initial and retest lead results must be posted where they can be seen by parents. While touring the classroom LPA observed that water is not made readily available for children in the classroom. Per S1 children bring water bottles from home and they are kept in their backpacks. S1 Also stated that drinking fountains outdoor can be accessed if needed. LPA informed AP that water must be available both indoors and outdoors so children can drink freely throughout the day. A deficiency was cited to ensure that the water faucet with the exceedance will not be used as a drinking source or food preparation source for the children. A deficiency will also be cited to ensure non-contaminated water is made readily available indoors.

There were 11 children and two staff present during the inspection. At 11:00 a.m. LPA observed 11 children outside of the preschool area eating lunch at picnic tables in the cafeteria area. Children were being supervised by State Preschool Teacher's assistant, Staff Two (S2) and Transitional Kindergarten Teacher, Staff Three (S3) who is not a part of the California State Preschool Program (CSPP). LPA observed the CSPP teacher, Staff One (S1) in the classroom near by who stated they were on their lunch break. -------PAGE 1
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 4


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: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444
VISIT DATE: 12/14/2022
NARRATIVE
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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.

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

Exit interview was conducted and Plans of Correction was reviewed and developed with Principal. A copy of this report and appeal rights were discussed and left with Assistant Principal, Christine Thomas , whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/14/2022 12:56 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: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2022
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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Water source identified with ALE was corrected prior to inspection. LPA observed new faucet and operable water LPA received confirmation email that Tubing and filters have been replaced along with completed, LIC 9276 Follow-Up checklist for Water Sampling During a Corrective Plan.
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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 one drinking water sources has an action level exceedance. This poses a potential Health, Safety or Personal Rights risk to children in care.
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Type B
12/15/2022
Section Cited

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101639.2(c) Drinking Water
(c) Drinking water from a non contaminating fixture or container shall be readily available to children both indoors and in the outdoor activity area.
This requirement was not met as evidence by:
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Per AP,
Water bottles will be purchased and added to the classroom by Friday 12/16/22. AP will emai picture to LPA.
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Based on observation the licensee did not ensure water was made readily available to refill water bottles provided by parents or provide children water who did not being water bottles from home indoors. Children do have access to water outdoors. This poses a potential Health, Safety or Personal Rights risk to 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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/14/2022 12:56 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: ANNALEE AVE ELEMENTARY PRESCHOOL
FACILITY NUMBER: 198019444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited

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101216.3(c)(1)(C) Teacher-Child Ratio
(c)...programs funded by the California Department of Education and operating under Title 5...(C) Preschool (36 months to enrollment in kindergarten) - 1:8 adult-child ratio, 1:24 teacher-child ratio.
This requirement was not met as evidence by:
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Per Assistant Principal, there are three assistants who rotate in the classroom and two at all times with the teacher. One asstatant was out today. AP states that Certified teacher will take lunch break during nap time. If an assistant is out for the day, designated Admin will step in to cover ratio.
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Based on observation the licensee did not Title 5 ratio was followed. S2 (assistant) was supervising 11 children. Other adult near by was supervising another class of 12 children. This poses a potential Health, Safety or Personal Rights risk to children in care.
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AP will create a break schedule and send LPA a copy by POC date.

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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: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4