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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197405853
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:13:46 PM

Document Has Been Signed on 05/22/2024 02:13 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:STAGG STREET ELEMENTARY SCHOOLFACILITY NUMBER:
197405853
ADMINISTRATOR/
DIRECTOR:		BRANDON, PATRICIAFACILITY TYPE:
850
ADDRESS:7839 AMESTOY AVENUE, RM. 15TELEPHONE:
(818) 881-9850
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 15DATE:
05/22/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Ana Valenzuela, Principal TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced case management inspection on 05/22/2024 for the purpose of addressing an Action Lead Exceedance (ALE) at the facility. LPAs arrived at the facility at 11:25AM and met with Tarynne Fraigun, School Administrative Assistant, who instructed Aicha Salmi, Plant Manager, to guided LPA on a tour of the facility. There were 15 children in care and 2 staff present upon arrival. LPA was later met by Ana Valenzuela, Principal.

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 of the Lead Water Testing results conducted at the facility on 11/11/2022. The sample testing was for Outlets "A" with results above 5.5 ppb which is considered an exceedance. Outlet "A" was reported to have an exceedance of 7.29 ppb.

During today’s visit, Principal provided LPA a copy of the Facility Sketch (LIC 999) in which all water outlets are noted, a copy of the initial water testing results summary and plan of corrections for Outlet "A” . LPA took photos of all water outlets tested.

Documents pending are as followed:
External Water Sampler Self-Certification Form (LIC 9275)
Child Care Center Sampling Checklist Form (LIC 9276)
Copy of water retesting results summary for Outlets "A"
Plan on how often Outlet "A" filter will be serviced.
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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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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: STAGG STREET ELEMENTARY SCHOOL
FACILITY NUMBER: 197405853
VISIT DATE: 05/22/2024
NARRATIVE
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Based on interviews and results reported to the Department, it has been determined that STAGG STREET ELEMENTARY SCHOOL violated Child Care Licensing Regulation Division 12, Chapter 1, Subchapter 5 101700.3 (b)(1) California Lead Action Level at Child Care Centers.

A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care. Refer to LIC 809-D for deficiency page.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Ana Valenzuela, Principal
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 02:13 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 05/22/2024 at 02:01 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: STAGG STREET ELEMENTARY SCHOOL
FACILITY NUMBER: 197405853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
101700.3(b)(1)

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(b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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Per Principal, the following documents will be submitted to LPA via email by POC due date:External Water Sampler Self-Certification Form (LIC 9275)
Child Care Center Sampling Checklist Form (LIC 9276)
Copy of water retesting results summary for Outlets "A"
Plan on how often Outlet "A" filter will be serviced.
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This requirement was not met as evidence by: Based on results submitted to the Department, the facility did not comply with the section cited above in the water outlet identified as "A" tested above 5.0 ppb on 11/11/2022 exceeding allowable limit for lead which poses a potential Health, Safety or Personal Rights risk to persons 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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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