300613937-3-2-2023-06-CC-PRIS-CPJN7Q-20230302091307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613937
Report Date: 03/02/2023
Date Signed: 03/02/2023 09:13:56 AM

Document Has Been Signed on 03/02/2023 09:13 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	ANAHEIM ELEMENTARY SCHOOL DISTRICT MANN		FACILITY NUMBER:	300613937
ADMINISTRATOR:	JELINEK, VIVIANA		FACILITY TYPE:	850
ADDRESS:	600 WEST LA PALMA		TELEPHONE:	(714) 517-8727
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 24	CENSUS: 19	DATE:	03/02/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jessica Cabral , FAmily Services Assistant		TIME COMPLETED:	09:30 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	Licensing Program Analyst (LPA) Rivas P conducted an unannounced Case Management visit. LPA met with Family Services Assistant Jessica Cabral to discuss the Lead Sampling Testing conducted on 12/20/2022. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires all licensed Child Care Centers (CCC’s) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every five years after the date of the first test. Community Care Licensing was notified that lead water testing conducted at the facility on 12/20/2022 failed allowable limit for lead. The Purpose of today’s visit is to follow up lead testing results of Action Level Exceedance (ALE). Instructions for required lead testing are outlined in PIN 21-21-CCP. This PIN which contains Written Directives, have the same force and effects as the regulations contained in Title 22 of the California Code of Regulations. Child Care Centers are expected to use an Environmental Laboratory Accreditation Program (ELAP), for lead testing. Accreditation from the California Environmental Laboratory Accreditation Program, known as an ELAP laboratory, is equipped to measure the amount of lead in parts per billion (ppb) unit of measurement. Teacher was advised that the Lead Sample Report was to be posted. Teacher stated the outlet A in the classroom with a high levels of lead at 370 Outlet A, Outlet B with ALE of 380 had been made inoperable pending remediation. As of 03/01/23 LPA was advised new results were received. The test result were posted. The teacher stated that the faucet was not in use since 2020 (due to Covid-19). The children bring in their own bottles of water and or water is provided by facility. LPA verified that the test sample results were posted and verified documentation of the action that the facility had taken. During the time of the remediation faucet A and B was out of use, the teacher stated that the facility was using bottled water and children were bringing water from home. Page 1`

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ANAHEIM ELEMENTARY SCHOOL DISTRICT MANN	FACILITY NUMBER: 300613937
	VISIT DATE: 03/02/2023

NARRATIVE

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(Page 2 of Report)

Based on LPA's observation, interview with Family Service Assistant Jessica Cabral , review of facility's sketch and documentation regarding action taken to fix the identified outlets, the following violation was observed and is being cited in accordance with Written Directives Section 101700.3 (b)(1) California Lead Action Level at Child Care Centers is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with Family Service Assistant .

A notice of site visit was given and must remain posted for 30 days. The Notice of Site Visit was given and discussed it must be posted as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to do so will result in a civil penalties of $100.00

Appeal Rights and deficiency were explained. Ms. Jessica Cabral was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/02/2023 09:13 AM - It Cannot Be Edited

Created By: Pat Rivas On 03/02/2023 at 08:47 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ANAHEIM ELEMENTARY SCHOOL DISTRICT MANN	FACILITY NUMBER: 300613937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/03/2023 Section Cited	1 2 3 4 5 6 7	101700.3 California Lead Action Level at Child Care Centers (b) Testing results...comparing to the Action Level. (1) A result with values of 5.5 part per billion or greater shall be deemed an Action Level Exceedance. This requirement
	8 9 10 11 12 13 14	was not met evidenced by:Lab report water analysis from Outlet A (370ppb) & B (380 ppb) taken on 12/20/2022 indicated levels of lead in exceedance. This poses a potential risk to the health, safety and personal rights of children in care.	8 9 10 11 12 13 14	Deficiency cleared .
	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:

Rina Lopez

LICENSING EVALUATOR NAME:

Pat Rivas

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

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