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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600834
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:10:10 AM

Document Has Been Signed on 02/16/2023 10:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:UCLA INTERV PROG DEV HANDICAPPED INF & CHILDFACILITY NUMBER:
191600834
ADMINISTRATOR:DANE FITZMORRISFACILITY TYPE:
830
ADDRESS:1000 VETERAN AVE 23-31, 24-17TELEPHONE:
(310) 825-4821
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY: 26TOTAL ENROLLED CHILDREN: 23CENSUS: 12DATE:
02/16/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Dane Fitzmorris, Director TIME COMPLETED:
10:20 AM
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On 02/16/2023 at 8:35 AM, Denise Miranda, Licensing Program Analyst (LPA), conducted an unannounced case management visit for the purpose of following up on Action Lead Exceedance (ALE), Facility Inspection. LPA met with Dane Fitzmorris, Director, and toured the facility.

Community Care Licensing was notified of the results of the Lead Water Testing conducted at the facility on 01/26/2023. The sample test for the sink, located in Room 24-13 a cubby room, identified on the facility sketch by letter “C”, tested at 6.4 ppbp/ug L, and sample test for the sink, located in Room 23-31 exercising room, identified on the facility sketch by Letter “F”, tested at 6.9 ppb/ L. which exceeds allowable limit for lead. Test Samples testing over 5.5 ppb/ug L and above is considered an exceedance.

LPA observed the the area of sink located in room 24-13, that was removed and in Room 23-31 facility removed the faucet and placed a signed “do not use this sink”.

The Director is reporting that the classroom 23-31 is in use only for children exercising. Facility will provide water it children from the kitchen water filtration system and from room 24-13 cubby room, facility removed the sink and the sink will be replace no later than tomorrow.

Licensee has posted testing results, in a location (cub room and observation room) consistent with the requirements of subsection (b) of section 1596.8595 of the Health & Safety Code, for parents and families to view at the facility within 24 hours of receiving the results from the Department. Facility has notified all parents or guardians of children in care of Lead Exceedance results and what has been done to date and remediation plan for water outlet “C and "F".

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: UCLA INTERV PROG DEV HANDICAPPED INF & CHILD
FACILITY NUMBER: 191600834
VISIT DATE: 02/16/2023
NARRATIVE
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During today’s visit LPA took pictures of the location of the water faucet (C) and (F). LPA received via email copies of External Water Sampler Self-Certification Form (LIC 9275); Child Care Center Sampling Checklist Form (LIC 9276); Facility Sketch (LIC 999) in which all water outlets are noted; and copy of water testing results summary. .

During today’s visit one Type B violation is being issued per PIN 21-21-CCP, Title 22 Regulations, Division 12, and Subchapter 5: 101700.3(b)(1) California Lead Action Level at Child Care Centers: A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

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.

For more information, go to the California Childhood. Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb or call them at (510) 620-5600. LPA will email and provide the Director with the Provider Information Notice (PIN) 21-21CCP and Lead Testing in Child Care Centers Frequently Asked Questions.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 daysduring the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

A copy of this Report (LIC809 & LIC809D), Appeal Rights (LIC9058), and Notice of Site Visit (LIC9213) were reviewed and provided to Dane Fritzmorris, Director.

SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2023 10:10 AM - It Cannot Be Edited


Created By: Denise Miranda On 02/16/2023 at 09:31 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: UCLA INTERV PROG DEV HANDICAPPED INF & CHILD
FACILITY NUMBER: 191600834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1) California Lead Action Level at Child Care Centers: A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This Requirement is not met as evidenced by:
Based on observation, interview
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The facility will have the sink located in room 24-13 cub room replaced no later than tomorrow and sink located in room 23-31 the faucet will be replaced and new lead test will
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and record review, Water faucet "C" tested at 6.4 ppb/ug L and
Water faucet “F” tested at 6.9 ppb/ug L, which exceeds allowable limit for lead, which poses a potential Health or Safety, or personal rights risk to persons in care.
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be reschedule. Facility provide water to children from the kitchen water filtration system.

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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:Rita Ramos
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


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