197402655-1-10-2023-30-CC-LCLN-CMXV5K-20230110150804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197402655
Report Date: 01/10/2023
Date Signed: 01/10/2023 03:08:11 PM

Document Has Been Signed on 01/10/2023 03:08 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:	UCLA EARLY CARE & EDUC. UNI. VILLAGE C.C.C.		FACILITY NUMBER:	197402655
ADMINISTRATOR:	NEGIN ZOMORODI		FACILITY TYPE:	850
ADDRESS:	3233 S SEPULVEDA BLVD		TELEPHONE:	(310) 915-5827
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY: 90	TOTAL ENROLLED CHILDREN: 90	CENSUS: 53	DATE:	01/10/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	NIKKI ZOMORODI, DIRECTOR		TIME COMPLETED:	03:30 PM

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 01/10/2023 Licensing Program Analyst (LPA) Lisa Clayton, conducted an unannounced case management - deficiencies visit. LPA was greeted by Director Nikki Zomorodi. LPA Clayton toured the facility and observed 53 children being care for and supervised appropriately by 5 teachers.

LPA Clayton explained the purpose of the visit. The department has received testing results, indicating a water outlet has been identified with an Action Level Exceedance (ALE) in the amount of lead in water being 5.5 ppb, or greater.

During today’s inspection, LPA Clayton reviewed the following documents: Child Care Center Sampling Checklist Form (LIC 9276), External Water Sampler Self-Certification Form (LIC 9275) Facility Sketch labeled with locations of all water outlets that were tested, and a copy the Parents notification.

Lead water testing samples collected on 10/21/2022 revealed that levels of lead were beyond allowable amount deemed by the State of California. Director Zomorodi stated the facility has notified all parents via email and posted the Lead Testing Results on the parent board.

LPA observed the water outlet (drinking fountain) in question, which is located in the “Otter” Classroom (room 149). Per Director Zomorodi, the children have not used the water fountain in question since March 2020. Due to the pandemic, the Children have continued to bring refillable water bottles from home. LPA Clayton observed the above-mentioned drinking fountain has made inaccessible to children as it has a box over it, covered with colored contact/wallpaper. See LIC 812 DRINKING FOUNTAIN PHOTO.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: UCLA EARLY CARE & EDUC. UNI. VILLAGE C.C.C.	FACILITY NUMBER: 197402655
	VISIT DATE: 01/10/2023

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

Due to the Lead water testing samples collected on 10/212022 which are exceed the allowable amount deemed by the State of California, per the Written Directives for Lead Testing of Water in Licensed Child Care Center, AB 2370 the following deficiency is cited (See next page 809-D).

For more information, go to the California Childhood Lead Poisoning Prevention Branch's website at www.cdph.ca.gov/programs/clppb Please see Provider Information Notice (PIN) 20-01-CCP for more information about lead toxicity prevention.

An Exit interview was conducted, and appeal right explained. A copy of this report, appeal rights, and Notice of Site Visit provided to Nikki Zomorodi, Director.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/10/2023 03:08 PM - It Cannot Be Edited

Created By: Lisa Clayton On 01/10/2023 at 02:36 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 & EDUC. UNI. VILLAGE C.C.C.	FACILITY NUMBER: 197402655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 01/10/2023 Section Cited 101700.3(b)(1)	1 2 3 4 5 6 7	California Lead Action at Child Care Centers (b)Testing results with fractional ppb readings....(1) A result of 5.5ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidence by the Action Level Exceedance results revealed	1 2 3 4 5 6 7	UCLA University Apartments maintenance has turned off the water source. The maintenance manager and Center Director have concluded that the water fountain will be removed, and the wall is to be patched and painted the week of January 30, 2023.
	8 9 10 11 12 13 14	that levels of lead were beyond allowable amount deemed by the State of California, if not corrected this poses a potential Health and Safety or Personal Rights risk to children in care.	8 9 10 11 12 13 14	Until then, the fountain will remain turned off. LPA Clayton instructed Director Zomorodi to send photos to the ESRO upon completion.
	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:

Mary Ruiz

LICENSING EVALUATOR NAME:

Lisa Clayton

LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3