<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601484
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:13:55 PM

Document Has Been Signed on 04/06/2023 04:13 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:UCLA EARLY CARE AND EDUCATIONFACILITY NUMBER:
191601484
ADMINISTRATOR:AMY AGNEWFACILITY TYPE:
850
ADDRESS:101 S. BELLAGIO DR.TELEPHONE:
(310) 825-5086
CITY:LOS ANGELESSTATE: CAZIP CODE:
90095
CAPACITY: 122TOTAL ENROLLED CHILDREN: 140CENSUS: DATE:
04/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Director Amy AgnewTIME COMPLETED:
11:30 AM
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
On 04/06/2023 at 9:02 AM, Lilia Hernandez and Antonio Almanza, Licensing Program Analysts (LPAs) conducted an unannounced case management visit for the purpose of following up on Action Lead Exceedance (ALE), Facility Inspection. LPAs met with Amy Agnew, Director and toured the facility. During today’s visit there are 77 children and 14 teachers.

Community Care Licensing was notified of the results of the Lead Water Testing conducted at the facility on 02/14/2023. The sample test for the Water Outlet located on the Playground in front of the office, identified on the facility sketch by letter “D”, tested at 8.0 bbp, and water fountain located in front of the Koalas classroom, identified on the facility sketch by letter “CC”, tested at 48.00 bbp exceed allowable limit for lead. Test Samples testing over 5.5 ppb and above is considered an exceedance.

During today’s visit LPAs observed the Water Outlet “D” with a plastic bag covering it making it inaccessible. The Director is reporting they will be replacing the plumbing and will have Water Outlet “D” retested. LPAs observed water fountain “CC” has been removed.

Licensee has posted Lead testing results, in a location (facility lobby) 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 outlets “D” and “CC”.

During today’s visit LPA took pictures of the water outlets “D” and “CC”. LPA received 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 a copy of water testing results summary was provided during the visit.

SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: UCLA EARLY CARE AND EDUCATION
FACILITY NUMBER: 191601484
VISIT DATE: 04/06/2023
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
During today’s visit one Type B violation is being issued per PIN 21-21.1-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 emailed and provided 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 days during 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 the Director Amy Agnew.

SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/06/2023 04:13 PM - It Cannot Be Edited


Created By: Antonio Almanza On 04/06/2023 at 02:30 PM
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 EARLY CARE AND EDUCATION
FACILITY NUMBER: 191601484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
CCR
101700.3(b)(1)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Faciity has removed water outlet "CC".

Facility will have the plumbing in water outlet "D" replaced and retested by 04/28/23.
8
9
10
11
12
13
14
Based on observation, interview and record review, The facility water outlets D and CC tested in exceedence, which poses a potential Health or Safety, or personal rights risk to persons 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:Betty Bell
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3