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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370749
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:01:32 AM

Document Has Been Signed on 03/16/2022 11:01 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:SERRANO HEIGHTS ACADEMYFACILITY NUMBER:
304370749
ADMINISTRATOR:ANDERSON, MISTYFACILITY TYPE:
830
ADDRESS:6513 EAST SERRANO AVENUETELEPHONE:
(714) 637-4963
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY: 38TOTAL ENROLLED CHILDREN: 21CENSUS: 12DATE:
03/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Vik Gursahani, LicenseeTIME COMPLETED:
10:42 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stacy Torrence conducted an unannounced Case Management Inspection. LPA Torrence met with Licensee Vik Gursahani to discuss the Lead Sampling Testing conducted on 11/19/2021. Licensee was advised on 03/15/2022, that the Lead Sample Report was to be posted; LPA Torrence confirmed the Licensee posted the Lead Sample Report.

Mr. Gursahani stated the outlet with high lead levels is inoperable. Mr. Gursahani, had labeled, covered and taped the outlet. Mr. Gursahani stated plan to obtain a portable source of water for children and staff at the facility will be by utilizing the other two faucets located in the classroom and using a Brita Water Filter Pitcher.

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.

An Inspection and exit interview were completed with licensee. The report was reviewed and discussed. Appeal Rights was discussed. The facility representative was provided a copy of their 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.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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 03/16/2022 11:01 AM - It Cannot Be Edited


Created By: Stacy Torrence On 03/16/2022 at 10:19 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: SERRANO HEIGHTS ACADEMY
FACILITY NUMBER: 304370749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2022
Section Cited
CCR
101238(a)

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101238(a) Buildings and Grounds. The child care 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. The requirement is not met as evidence by LPA review of the facility's records. Based on facility's record review, it was discovered that outlet C had a high level of lead. This poses a potential risk to the health of children in care.
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Licensee had labeled, covered, and taped the outlet. Licensee is utilizing the other two available faucets in the classroom and a Brita Water Filter Pitcher for source of water.
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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:Thuy Ho
LICENSING EVALUATOR NAME:Stacy Torrence
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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