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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405810
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:10:31 AM


Document Has Been Signed on 09/27/2022 11:10 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:CALABASAS KLUBHOUSEFACILITY NUMBER:
197405810
ADMINISTRATOR:GOODMAN, APRILFACILITY TYPE:
850
ADDRESS:3655 OLD TOPANGA CANYON ROADTELEPHONE:
(818) 222-9791
CITY:CALABASASSTATE: CAZIP CODE:
90290
CAPACITY:115CENSUS: DATE:
09/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Director Bridget NelsonTIME COMPLETED:
11:20 AM
NARRATIVE
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On 9/27/2022 at 8:58 AM, Licensing Program Analyst (LPA) Antonio Almanza conducted an unannounced case management visit for the purpose of following up on Action Lead Exceedance (ALE), Facility Inspection. LPA met with Director Bridget Nelson/Carly Armacost. and toured the facility. During today’s visit there are 94 children and 18 teachers.

Community Care Licensing was notified of the results of the Lead Water Testing conducted at the facility on 7/15/2022. The sample test for the kitchen faucet, located next to the office, identified on the facility sketch by letter “B”, tested at 10 bbp/ug L, which exceeds allowable limit for lead. Test Samples testing over 5.5 ppb/ug L and above is considered an exceedance.

During today’s visit LPA observed water fountain identified on facility sketch. LPA observed the water fountain inoperable; covered with plastic and “do not use sign”, making it inaccessible.

Licensee has posted testing results, in a location (entrance of the facility and 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.

During today’s visit LPA took pictures of the water faucet (B). LPA received an email from the facility with 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 copy of water testing results summary.

The director is reporting that the facility does not prepare food in the kitchen for children in care. Meals are brought to the facility by an outside vendor Bright Belly. The kitchen sink is used for cleaning art supplies.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CALABASAS KLUBHOUSE
FACILITY NUMBER: 197405810
VISIT DATE: 09/27/2022
NARRATIVE
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During today’s visit one Type B violation is being issued under Title 22 Regulations, Division 12, and Chapter1: Physical Plant, Building and Grounds - Section 101238(a) The Child Care Center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

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 the director Provider Information Notice (PIN) 21-21-CCP 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 (LIC9099 & LIC9099d), Appeal Rights (LIC9058) and Notice of Site Visit (LIC9213) were reviewed and provided to the Director Bridget Nelson and Carly Armacost.

SUPERVISOR'S NAME: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/27/2022 11:10 AM - It Cannot Be Edited

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: CALABASAS KLUBHOUSE
FACILITY NUMBER: 197405810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited

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101238(a) Buildings and Grounds: The Child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well being of children , employee and visitors.
This requirement not met as evidence by:
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Based on interview and record review, results of the Lead Water Testing conducted on outlet "B" on 7/15/2022 were in exceedance, which poses a potential Health or Safety, or personal rights risk to persons in care.
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Director will speak with the Plant Manager to determine if water faucet will be replaced or removed. Director will provide LPA with an answer by 09/28/22 and final corrections will completed by 10/14/22.

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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: Rita RamosTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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