304370626-1-12-2023-06-CC-NKTN-CMZQHW-20230112111148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370626
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:11:56 AM

Document Has Been Signed on 01/12/2023 11:11 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:	OUSD-JORDAN PRESCHOOL		FACILITY NUMBER:	304370626
ADMINISTRATOR:	PEREZ, MONETTE		FACILITY TYPE:	850
ADDRESS:	4319 EAST JORDAN AVENUE		TELEPHONE:	(714) 628-5449
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	24	CENSUS: 0	DATE:	01/12/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jordin Olivo, CARES Supervisor		TIME COMPLETED:	10:30 AM

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Licensing Program Analyst (LPA) Nguyen Tran conducted an unannounced Case Management visit. LPA met with CARES Supervisor Jordin Olivo to discuss the Lead Sampling Testing conducted on 10/29/22.

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 10/29/2022 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.

Supervisor was advised on 01/12/23 that the Lead Sample Report was to be posted. OUSD Maintenance Supervisor Adriana Hernandez stated the outlet B in between Pre-K rooms with a high levels of lead at 8.5ppb, was made inoperable and the test result was posted on 1/12/2023. LPA verified that the test sample results were posted and outlet B was made inoperable. During the time of the faucet B was out of use, Site Supervisor stated that the facility was providing water bottles to the children in care.

Based on LPA's observation and interview with Supervisor, 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.
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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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: OUSD-JORDAN PRESCHOOL	FACILITY NUMBER: 304370626
	VISIT DATE: 01/12/2023

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(Page 2 of Report)

Exit interview conducted and report was reviewed with CARES Supervisor Jordin Olivo. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights and deficiency were explained. The Supervisor was provided a copy of appeal rights (LIC 9058) 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.

(End of Report)

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/12/2023 11:11 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: OUSD-JORDAN PRESCHOOL	FACILITY NUMBER: 304370626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/13/2023 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 was not met evidenced by:	1 2 3 4 5 6 7	Site Supervisor stated that facility will submit all required documentation including LIC 9275, 9276, plan of correction and details of steps taken to resolve the deficiency.
	8 9 10 11 12 13 14	Lab report analysis water from Outlet B (8.5 parts per billion) taken on 10/29/2022 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
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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	TELEPHONE: (714) 795-0859
LICENSING EVALUATOR NAME: Nguyen K Tran	TELEPHONE: (714) 658-6048
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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