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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870577
Report Date: 03/21/2024
Date Signed: 03/21/2024 10:40:42 AM

Document Has Been Signed on 03/21/2024 10:40 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
MONTEREY PARK S WEST, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:WILLOWBROOK CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191870577
ADMINISTRATOR:SONIA LOVEFACILITY TYPE:
850
ADDRESS:12829 SO. JARVIS AVE.TELEPHONE:
(310) 352-4486
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 73TOTAL ENROLLED CHILDREN: 65CENSUS: 36DATE:
03/21/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Site Supervisor Lucy BryantTIME COMPLETED:
11:00 AM
NARRATIVE
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On March 21, 2024, at 9:30AM, Licensing Program Analysts (LPAs) A. Wallin and T. Tran conducted an unannounced case management inspection and was met with site supervisor, Lucy Bryant, who provided assistance. LPA toured the facility and a census was taken. LPA observed today's census was 8 staff and 36 children.

The purpose of today's inspection was to go over the water lead test results discovered on 2/28/2024. Results show that three classroom water fountain sources had action level exceedance of lead. The water fountain, sample site A, located in the toddler room had a lead result of 71. 0 ppb. The water fountain, sample site E, located in room 1B had a lead result of 6.900 ppb. The water fountain, sample site H, located in room 1A had a lead result of 25.00 ppb. Per site supervisor, facility temporary fix for all water fountain sources was to tape them off. Photo evidence provided of taped water fountains via email. During inspection, LPAs observed facility capped off all water fountain sources to permanently disable the water fountains. Per site supervisor, facility utilizes Primo water company as main source of children’s water. During visit, LPAs collected Primo water service agreement form dated 05/18/2020. A deficiency was cited to ensure that the water fountain noted will not be used as a drinking source or food preparation source for the children.

The deficiency listed on the following page were observed by LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. During facility visit, LPAs collected the plan of correction (POC) to permanently disabled the water fountain. POC is cleared during today's visit.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the site supervisor, Lucy Bryant.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Angelica Wallin
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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Document Has Been Signed on 03/21/2024 10:40 AM - It Cannot Be Edited


Created By: Angelica Wallin On 03/21/2024 at 10:23 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: WILLOWBROOK CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 191870577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2024
Section Cited
CCR
101700.3(b)(1)-(b)

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Result with values of 5.0 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidence by record review. Lead test results showed that three water sources had an action level exceedance.
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Facility had provided correction record completed on 3/21/24 all water outlets have been capped off. Facility provides filtered water for the children to drink.
POC cleared during today's visit.
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LPA observed all three outlets have been been capped off.This is a potential risk to the health and safety of the children in care.
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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:Karen Chambers
LICENSING EVALUATOR NAME:Angelica Wallin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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