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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402656
Report Date: 01/10/2023
Date Signed: 01/10/2023 03:02:48 PM

Document Has Been Signed on 01/10/2023 03:02 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:
197402656
ADMINISTRATOR:NEGIN ZOMORODIFACILITY TYPE:
830
ADDRESS:3233 S SEPULVEDA BLVD.TELEPHONE:
(310) 915-5827
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 16DATE:
01/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:NIKKI ZOMORODI, DIRECTORTIME COMPLETED:
03:30 PM
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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 16 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 (fountain) in question, which is located outside, in the infant play area, between the Seahorse and Sea Turtle Classrooms. 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. See LIC 812 DRINKING FOUNTAIN PHOTO.

LPA Clayton advised Director Zomorodi to have the fountain bagged by the facility maintenance department and to label the fountain with postings that states “Teachers/Staff: DO NOT USE, OR ALLOW THE CHILDREN TO USE THIS FOUNTAIN”, and send photos of the completed direction to the ESRO.

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)
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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: UCLA EARLY CARE & EDUC. UNI. VILLAGE C.C.C.
FACILITY NUMBER: 197402656
VISIT DATE: 01/10/2023
NARRATIVE
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Due to the Lead water testing samples collected on 10/21/2022 which exceed the allowable level 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)
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Document Has Been Signed on 01/10/2023 03:02 PM - It Cannot Be Edited


Created By: Lisa Clayton On 01/10/2023 at 12:49 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: 197402656

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)

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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
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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.
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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.
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Until then, the fountain will remain turned off. LPA Clayton instructed Director Zomorodi to have the maintenace department bag the water fountain, and label the fountain with postings that states “Teachers/Staff: DO NOT USE, OR ALLOW THE CHILDREN TO USE THIS FOUNTAIN”. LPA Clayton instructed Director to send photos of the completed direction to the ESRO, in addition to completed photos of the fountain removal.

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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: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)
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