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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270776
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:42:31 PM


Document Has Been Signed on 02/15/2023 02:42 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:ANAHEIM ELEMENTARY SCHOOL DISTRICT MADISONFACILITY NUMBER:
304270776
ADMINISTRATOR:JELINEK, VIVIANAFACILITY TYPE:
850
ADDRESS:1510 SOUTH NUTWOOD STREETTELEPHONE:
(714) 517-8935
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:72CENSUS: 19DATE:
02/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Remedios Cebeda TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bootorabi A & Rivas P conducted an unannounced Case Management visit. LPA met with teacher Maria Acebedo de Mengoni 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). LPA's later met with Martha Ravelo - Family Service Advocate to discuss unannounced Case Management visit.

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 340 was made inoperable and the test result were posted. The teacher stated that the faucet was not in use since 2020 (due to Covid-19). The School District had sent staff to come to replace the faucet A.
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 faucet A is out of use, the teacher stated that the facility was using bottled water and children were bringing water from home.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ANAHEIM ELEMENTARY SCHOOL DISTRICT MADISON
FACILITY NUMBER: 304270776
VISIT DATE: 02/15/2023
NARRATIVE
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(Page 2 of Report)

Based on LPA's observation, interview with Family Service Advocate Martha Ravelo , review of facility's sketch and documentation regarding action taken to fix the identified outlet, 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 Advocate .

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. The Director 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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/15/2023 02:42 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: ANAHEIM ELEMENTARY SCHOOL DISTRICT MADISON
FACILITY NUMBER: 304270776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited

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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.
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Teacher stated that facility followed Written Directives and submitted all required documentation
including LIC 9275, 9276, plan of correction and details of steps taken to resolve the deficiency.
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This requirement was not met evidenced by:Lab report analysis water from Outlet A (340 parts per billion) 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.
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 Faucets were replaced. AFter retest if levels are still in exceedance director will have the faucets removed, repaired, and retested.

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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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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