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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411187
Report Date: 05/07/2024
Date Signed: 05/07/2024 10:55:46 AM

Document Has Been Signed on 05/07/2024 10:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CHEREMOYA AVENUE ELEMENTARY SCHOOL STATE PRESCHOOLFACILITY NUMBER:
197411187
ADMINISTRATOR/
DIRECTOR:		GORSUCH, MICHELLEFACILITY TYPE:
850
ADDRESS:6017 FRANKLIN AVENUE, ROOM 23TELEPHONE:
(323) 464-1722
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY: 23TOTAL ENROLLED CHILDREN: 10CENSUS: 7DATE:
05/07/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Principal Sara LucasTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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At 2:30 pm Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced case management inspection for an Action Level Exceedance (ALE) detected in water fixtures in the facility. A COVID 19 risk assessment was conducted prior to entering the facility. LPA met with Principal, Sara Lucas during the visit. Tour was given by Plant Manager Mr. Jones. Census was taken

Analyst reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

Facility provided facility sketch and required forms LIC 9276, LIC 999 and LIC 9275 to the department. On 03/08/2024, the Department received notification from the State Water Resources Control Board(SWRCB), Division of Drinking Water (DDW).

The SWRCB report indicated the facility was inspected and samples were collected on 10/21/2022. Faucets reported with 5.5 ppb or greater lead exceedance levels were as follows:--------------------------------------------------------pg.1 of 2 ----------------------------------------------------------
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHEREMOYA AVENUE ELEMENTARY SCHOOL STATE PRESCHOOL
FACILITY NUMBER: 197411187
VISIT DATE: 05/07/2024
NARRATIVE
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  • Room # 2 Sink fixture (staff room) (A) (490.000 UG/L)
  • Hallway Water fountain fixture (B) (19.800 UG/L)
  • Room # 2 Water fountain fixture (C) (117.000 UG/L)
  • Room # 2 Sink fixture (C30) (6.880 UG/L)

LPA observed that both water fountains are not on and not used by children. Per Teacher children bring water bottles from home. The Department received updated checklist and paper work noting point of use filters were installed- however no new results have been received .

Grant funding will be available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information, including additional resources please visit
https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information

See LIC809D for Type B deficiency cited.

A notice of site visit was also provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative, Teacher, Mariana Harutyunyan
------------------------------------------------ pg 2 of 2 ----------------------------------------
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2024 10:55 AM - It Cannot Be Edited


Created By: Roxana Lopez On 05/07/2024 at 10:39 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHEREMOYA AVENUE ELEMENTARY SCHOOL STATE PRESCHOOL
FACILITY NUMBER: 197411187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1)California Lead Action Level at Child Care Centers. (b) Testing results with...readings of 0.5 ppb or greater.., before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not me at evidenced by
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Per Prinicpal they will follow up to confirm these faucets/ water fountains have been fixed and retested and will contact for new results to be updated.
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Based on ispection, the licensee did not comply with the directive above, as that Sink faucet and or water fountain A, B, C & C30 tested with an Action Level Exceedance (ALE) of 490.00, 19.800, 117.00 & 6.880 ppb. This poses a potential health and safety risk to 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Roxana Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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