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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191606358
Report Date: 02/23/2023
Date Signed: 02/23/2023 04:06:35 PM

Document Has Been Signed on 02/23/2023 04:06 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SAMUEL GOLDWYN FOUNDATION CHILDREN'S CENTERFACILITY NUMBER:
191606358
ADMINISTRATOR:KAE CONNORSFACILITY TYPE:
850
ADDRESS:2114 PONTIUS AVENUETELEPHONE:
(310) 445-8993
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 46DATE:
02/23/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Summer Saito and Kim Thorstenson-RootTIME COMPLETED:
10:55 AM
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On 2/23/2023, Licensing Program Analyst (LPA) Judy Laureano conducted an unannounced case management visit. LPA Laureano was greeted by Summer Saito-Health and Safety Director and granted entry into the facility. Health and Safety Director guided LPA on a tour of the facility. There were 8 staff members and 46 preschool children. Regional Manager Kim Thorstenson-Root was also present during today’s inspection.

Facility operates and Infant License with Facility #191606360 and School Age License with Facility #197414108. LPA confirmed with facility the faucet/water outlet identified with lead exceedence falls under the preschool.

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 12/2022 exceeded allowable limit for lead. Samples testing over 5.5 ppb/ug L and above is considered an exceedance. The Purpose of today’s visit is to follow up lead testing results of Action Level Exceedances (ALE) and conduct an inspection.

On 2/15/2023 LPA Laureano received notification from director, Kae Connors, informing CCL that LEAD water testing has been completed in the facility and will prepared the following documents to submit to LPA: LIC 9275, LIC 9276, Facility Sketch (water faucets/outlets identified), pictures of fixtures and test results. LPA Laureano took pictures of faucet/ outlet on today's inspection.

The facility has been identified to have 1 water faucet/outlet located in the Castle Room (Preschool) with an Action Level Exceedance (ALE) in the amount of lead in water being 5.5pb, or greater. LPA confirmed with Health and Safety Director and Regional Manager the following outlet/faucets was identified as exceedance of lead and shall remain inoperable.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SAMUEL GOLDWYN FOUNDATION CHILDREN'S CENTER
FACILITY NUMBER: 191606358
VISIT DATE: 02/23/2023
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Castle Room- Preschool Room-water faucet/outlet

LPA Laureano observed sink and water outlet identified with an Action Level Exceedance to be made inaccessible to the children in care. LPA observed area to be taped off with water fountain blocked off. LPA interviewed Health and Safety Director and staff to ensure children do not have access to the identified sink/outlet that has been identified as exceedance of lead.

Children are have access to water via filter water pitcher in each classroom and water pitcher when children are outdoors. LPA observed a filter water and cups in the classroom, making water readily accessible to children in care.

Based on observation, interviews and sampling records it has been determined that there was a violation of Licensing Regulation Title Division 12, Chapter 1, Subchapter 5 – 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”. Lead water testing samples taken on 12/2022 revealed that levels of lead were beyond allowable amount deemed by the State of California. This facility is being cited (1) deficiency during today’s visit 02/23/2023. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care. In Accordance with California Code of Regulations. Refer to LIC 809-D.

LPA discussed Proof of Correction (POC) with Health and Safety Director and Regional Manager. All faucets identified with an Action Lead Exceedance of 5.5 ppb or over have been made inaccessible to the children in care. These outlets will not be accessible for use until a retest has occurred. A notification of letter was drafted by facility and sent out to parents with notification of cease of water outlets and remediation for planned for water outlets or alternative. Facility will send LPA a copy of the letter via email by 3/3/2023. Facility will work on scheduling for a second test of identified outlet as repairs have been completed. Director will LPA a copy of the re-test summary once completed.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SAMUEL GOLDWYN FOUNDATION CHILDREN'S CENTER
FACILITY NUMBER: 191606358
VISIT DATE: 02/23/2023
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Instructions for required lead testing are outlined in PIN 21-21. 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 Care Child 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 a parts per billion (ppb) unit of measurement.

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. Please see Provider Information Notice (PIN) 20-01-CCP for more information about lead toxicity prevention

Health and Safety Director, Summer Saito, received Notice of Site Visit and copy of this report

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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Document Has Been Signed on 02/23/2023 04:06 PM - It Cannot Be Edited


Created By: Judy Laureano On 02/23/2023 at 10:16 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: SAMUEL GOLDWYN FOUNDATION CHILDREN'S CENTER
FACILITY NUMBER: 191606358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1)
A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance
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Faucet/outlet has been placed inoperable. Facility submitted a plan of correction to LPA Lowe on 2/10/2023. Water outlets in Castle Room-preschool have been taped/blocked off. Children in care have access to filter water via pitcher and addtional filter water source in the classroom.
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Based on observation, interview and review of Lead water testing samples taken on 12/2022 revealed that levels of lead were beyond allowable amount deemed by the State of California. Castle Room water faucet/outlet had a lead exceedance levels. This poses a potential health and safety risk to children in care.
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Facility has notified parents and copy of notification was emailed to LPA. These outlets will not be accessible for use until a retest has occurred. Director will send LPA a copy of the re-test summary once completed.

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


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