304371120-4-26-2023-06-CC-PDUN-CR9QX7-20230426123304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371120
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:35:11 PM

Document Has Been Signed on 04/26/2023 12:35 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:	COMMUNITY CARE CLUB @ COMMUNITY ROOTS ACADEMY		FACILITY NUMBER:	304371120
ADMINISTRATOR:	WALTERS, MARIA FERNANDA		FACILITY TYPE:	840
ADDRESS:	29292 CROWN VALLEY PKWY		TELEPHONE:	(949) 831-4272
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	120	CENSUS:	DATE:	04/26/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Maria Walters Director		TIME COMPLETED:	12:50 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced Case Management visit for the purpose to discuss the Lead Sampling Testing conducted on 3/18/23 LPA met with Director Maria Walters , who was explained the reason for today’s visit. LPA observed 2 school age staff and 0 school age children in care at the time of visit.

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 3/18/23, 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.

Facility staff was advised on 4/21/23 that the Lead Sample Report was to be posted. LPA observed the facility had posted the Lead Sample Report.

Page 1 of 2

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Patricia Duron	TELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: COMMUNITY CARE CLUB @ COMMUNITY ROOTS ACADEMY	FACILITY NUMBER: 304371120
	VISIT DATE: 04/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Site ID J is the only site that tested positive. The faucet is located inside the kitchen. Site ID J is a food prep outlet that had a level of 9.880. Currently the outlet is not in use, and the site ID has yellow caution tape covering the sink and outlet and a sign that states Sink out of Order. Children do not drink from this outlet, and do not have access to kitchen. Director stated the facility is using filtered water delivered from Arrowhead for food prep and cooking.

Based on LPAs interview with staff, review of facility sketch and walk-through, 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 with Director Maria Walters. The report was reviewed and discussed. Appeal Rights were discussed. Director was provided 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 the Regional Office within 15 business days.

Director 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.

Page 2 of 2. End of Report.

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Patricia Duron	TELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 04/26/2023 12:35 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: COMMUNITY CARE CLUB @ COMMUNITY ROOTS ACADEMY	FACILITY NUMBER: 304371120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2023 Section Cited	1 2 3 4 5 6 7	101700.3 California Lead Action Level at Child Care Centers (b) Testing results with fractional ppb readings of 5.0 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.	1 2 3 4 5 6 7	LPA observed site ID J located in the kitchen.The site ID is located inside the kitchen. LPA observed the outlet is not in use, and has caution tape covering the sink/ outlet with a sign that states Sink out of Order. Director stated re-test will be done on 4/29/23 and will be submitted to LPA as soon as results are provided.
	8 9 10 11 12 13 14	Based on lab report analysis water from site ID J (9.880 parts per billion) taken on 3/18/23, indicated levels of lead in exceedance. Staff stated the water will be re-tested on Saturday 4/29/23.	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: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Patricia Duron	TELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3