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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801264
Report Date: 03/17/2023
Date Signed: 03/17/2023 10:36:24 AM


Document Has Been Signed on 03/17/2023 10:36 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:PSD/YUCAIPA HEAD STARTFACILITY NUMBER:
364801264
ADMINISTRATOR:DIANE MILIANFACILITY TYPE:
850
ADDRESS:12236 CALIFORNIA STREETTELEPHONE:
(909) 797-3585
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:66CENSUS: 0DATE:
03/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Facility Representative Jasmine AlvarezTIME COMPLETED:
10:45 AM
NARRATIVE
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On 03/17/2023, Licensing Program Analysts (LPAs) Perla Ordones and Laura Mejorado arrived at the facility to conduct a case management inspection regarding elevated levels of lead in the kitchen faucet (denoted as A on the lead results). During this inspection, LPAs toured the facility, inside and out, took census, verified facility associations, reviewed records, and discussed the following with Facility Representative Jazmine Alvarez.

LPAs toured the facility and observed that no children were present during this visit. LPAs inspected the kitchen area, specifically the sink in the the kitchen which maintained faucet A which had an Action Level Exceedance of 6.4ppb. LPAs observed faucet A to have a single hand washing spout and observed it to be made inaccessible to children and staff with a sign being taped over the sink with red tape. Per Facility Representative, since both kitchen faucet A and children's restroom sinks have been made inaccessible, with the children's sinks being made inaccessible out of precaution and not due to an ALE, a portable sink is being used by children and staff instead for hand washing. Additionally, the facility does not use kitchen faucet A for food preparation as food for the children is prepared off-site and water is provided to children through portable water dispensers.

Due to facility water outlets testing above approved lead levels, a deficiency has been cited. See LIC809D.

Additionally, the following resources were discussed and provided from PIN 21-21-CCP dated July 28, 2021:

Continued in LIC809C.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Perla OrdonesTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
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


Document Has Been Signed on 03/17/2023 10:36 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: PSD/YUCAIPA HEAD START
FACILITY NUMBER: 364801264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited

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California Lead Action Level at Child Care Centers 101700.3 (b)(1): A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This requirement is not met as evidence by:
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Facility agrees to maintain inaccessibility of faucet A which contains the Action Level Exceedance (ALE) until it is replaced and retested pursuant to section CCR 101705 in addition to returning a result at or below the ALE.
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Based on records review of required lead testing results, faucet A has tested with an Action Level Exceedance (ALE) of 6.4 ppb, which is higher than the 5ppb regulation, which poese a potential health, safety, and personal rights risk to persons in care.
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 Facility agrees tol notify CDSS with completion within 30 days and agrees to submit results upon receival

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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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Perla OrdonesTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PSD/YUCAIPA HEAD START
FACILITY NUMBER: 364801264
VISIT DATE: 03/17/2023
NARRATIVE
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101700.6 Grant Funding for Qualifying Child care Centers
(a) Senate Bill 862, Chapter 449, Statutes of 2018 allocated $5 Million to the State Water Resources Control Board for testing and remediation of lead in the drinking water of Child Care Centers based on the following criteria:
(1) Those that serve children zero to five years of age, with the highest priority for Child Care Centers that provide care for children zero to three years of age.
(2) Those that have 50 percent or more of their registered children who receive subsidized care.
(3) Those that operate only one facility.
(b) To determine a Child Care Center’s eligibility for possible funding the Department will provide access to a link to an online eligibility form located on the Department’s website and on Sacramento State’s Office of Water Programs website.
(1) A Child Care Center interested in financial assistance shall complete the eligibility form, which shall include instructions for completing and returning it, prior to receiving any grant funding for which it may qualify. To determine a Child Care Center’s eligibility for possible funding, the provider will need to complete an online eligibility form available at Office of Water Programs’ website

The facility failed to meet California Lead Action Level at Child Care Centers requirements per Title 22 regulations. See LIC809D for cited deficiency of the California Code of Regulations, Title 22.

Exit interview conducted and report was reviewed with Facility Representative Jazmine Alvarez. Appeal rights were provided and Notice of Site Visit (LIC9213) was provided. The Notice of Site Visit (LIC9213) was posted where the parent/guardian of children enter and exit the facility and must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result a civil penalty of $100.00.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Perla OrdonesTELEPHONE: (951) 782-4200
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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