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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270426
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:19:58 PM


Document Has Been Signed on 05/19/2022 12:19 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:CATALYST KIDS-TUSTIN MEMORIALFACILITY NUMBER:
304270426
ADMINISTRATOR:BOSCH, MARIANAFACILITY TYPE:
840
ADDRESS:12712 BROWNING AVE. P1 & LIBRATELEPHONE:
(714) 731-2051
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:70CENSUS: 0DATE:
05/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Stephanie Dang - Master TeacherTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst Carmen Odom conducted an unannounced Case Management visit. LPA met with Master Teacher Stephanie Dang, to discuss the Lead Sampling Testing conducted on 04/23/22. Staff was advised on 05/16/22 that the Lead Sample Report needs to be posted. LPA confirmed that Staff had posted the Lead Sample Report.

Staff stated the outlet with high levels of Lead are inoperable. The outlet is in room#1 temporarily closed off, they have made the drinking fountain/outlet that tested with high levels of Lead inoperable with plastic bag wrapped around the faucet, tapped and a sign posted “do not use”. Staff stated the replacement faucet arrived on 5/12/22, the faucet has been replaced and is currently being flushed for 3 weeks straight, and the company Adviro will be scheduling the retest for lead in the next two weeks. Source of drinking water is the filtered kitchen faucet that tested negative for Lead. The drinking fountain will not be used until the new lead sampling test comes back negative.

Based on LPAs record reviews the following violation was observed and is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 3, Section 101238(a) Buildings and Grounds is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the facility representative Stephanie Dang. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights were explained. The Licensee 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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Document Has Been Signed on 05/19/2022 12:19 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: CATALYST KIDS-TUSTIN MEMORIAL
FACILITY NUMBER: 304270426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/19/2022
Section Cited

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101238(a) Buildings and Grounds. The childcare center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children; employees and visitors. This requirement was not met as evidenced by:
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Based on facility Lead sampling tests it was discovered that drinking fountain/outlet in Rm 1 had high level of lead. This poses a potential risk to the health of children in care.
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Staff will provide copies of the new test results to licensing office.

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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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