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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270969
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:20:19 AM


Document Has Been Signed on 04/13/2023 10:20 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:MARTIN HEAD STARTFACILITY NUMBER:
304270969
ADMINISTRATOR:AMY QUEZADAFACILITY TYPE:
850
ADDRESS:1008 WEST RUSSELLTELEPHONE:
(714) 427-1290
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY:60CENSUS: 22DATE:
04/13/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amy Quezada - DirectorTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Odom conducted an unannounced Case Management visit. LPA Odom met with Director Amy Quezada, took a tour of the facility, and took census, LPA observed 5 staff members and 22 preschool age children. LPA discussed the Lead Sampling Testing conducted on 03/04/23 with Director. LPA Odom ensured the Lead Sample Report is posted. Licensee was advised on 04/12/23 the Lead Sample Report was to be posted; LPA confirmed the Licensee posted the Sample Report.

Director stated the outlets with high levels of Lead are inoperable. Outlet E is a classroom kitchen faucet in Room #1. Director stated Room #1 is currently not in use throughout the 2022-2023 school year, they plan to remediate the faucet. The faucet was replaced on 3/6/23 and they began to flush the faucet as of 4/11/23 for 30 seconds 4 times per day for the next 3 weeks. The faucet also has a sign posted “do not use”. Director stated they will schedule to retest the faucet for lead after they have concluded the flushing out. Source of drinking water is Brita filtered dispensers with disposable cups inside and outside the classrooms. Director stated they submitted the Lead forms to licensing on March of 2023 after the testing was completed.

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 101700.3 California Lead Action Level at Child Care Centers is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the Director Amy Quezada. 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: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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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Document Has Been Signed on 04/13/2023 10:20 AM - 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: MARTIN HEAD START
FACILITY NUMBER: 304270969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2023
Section Cited

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101700.3 California Lead Action Level at Child Care Centers (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 evidenced by:
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Director posted the lead sampling test results at the entrance of the facility. Room #1 is currently not in use and there was a sign posted on the faucet “do not use”. Director is remediating Outlet E by replacing the faucet, flushing it out and will retest for lead. Director stated they are using Brita filtered water dispensers with
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Based on facility Lead sampling tests it was discovered that Outlet E had high levels of lead. This poses a potential risk to the health of children in care.
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disposable cups in every classroom. Director will send the retest forms to licensing office by 5/13/23.

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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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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