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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413960
Report Date: 10/29/2025
Date Signed: 10/30/2025 10:15:08 AM

Document Has Been Signed on 10/30/2025 10:15 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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ST. TIMOTHY SCHOOL PRE-KFACILITY NUMBER:
197413960
ADMINISTRATOR/
DIRECTOR:		GEETHA SUGUNANFACILITY TYPE:
850
ADDRESS:10479 W. PICO BLVD.TELEPHONE:
(310) 474-1811
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 10DATE:
10/29/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Lorraine Speights/Lena Randle
TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 10/29/2025, Licensing Program Analyst (LPA) Judy Laureano conducted an unannounced case management inspection. LPA was greeted by Lorraine Speights, Preschool Director and School Principal Lena Randle. LPA Laureano toured the facility and observed 10 children with one staff member and director providing care and supervision. Facility is located on an elementary school campus.

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 that lead water testing conducted at the facility on 08/15/2025 exceeded allowable limit for lead. Samples testing over 5.5 ppb/ug L and above is considered an exceedance.

The Purpose of today’s visit is to follow up lead testing results of Action Level Exceedances (ALE) and conduct an inspection.

On 09/16/2025 LPA Laureano via email received the following documents from facility, Result Summary and photographs of water faucets/outlets identified.

The facility has been identified to have 3 water faucets/outlet with an Action Level Exceedance (ALE) in the amount of lead in water being 5.5pb, or greater. LPA Laureano confirmed with director and school Principal the following outlet/faucets, “A, E and F”, identified as exceedance of lead and shall remain inoperable. Per Preschool Director and School Principal, outlets have not been in use for approximately 4-5 years and will remain inaccessible. Preschool children do not have access to outlet/faucet identified.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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 RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ST. TIMOTHY SCHOOL PRE-K
FACILITY NUMBER: 197413960
VISIT DATE: 10/29/2025
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LPA Laureano observed all outlets identified with an Action Level Exceedance to be made inaccessible to the children in care. Preschool children do have access to the water outlets "A, E, and F". LPA interviewed staff to ensure children do not have access to the outlet/water faucets that have been identified as exceedance of lead.

Children have access to water via filtered water dispensers in the preschool classroom and children bring their own refillable water bottles. Water is made available both indoors and outdoors. LPA observed water dispenser in the facility as well as children’s refillable water bottles.

Based on observation, interviews and sampling records it has been determined that there was a violation of Licensing Regulation Title Division 12, Chapter 1, Subchapter 5 – California Lead Action Level at Child Care Centers 101700.3(b)(1), “A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance”. Lead water testing samples taken on 8/15/2025 revealed that levels of lead were beyond allowable amount deemed by the State of California. This facility is being cited (1) deficiency during today’s visit 10/29/2025. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care. In Accordance with California Code of Regulations. Refer to LIC 809-D.

LPA discussed Proof of Correction (POC) with Director and School Principal. All outlet/water faucets identified with an Action Lead Exceedance of 5.5 ppb or over have been made inaccessible to the children in care, per school principal, the outlets have not been in use by the children in care. The outlet/water faucets will not be accessible for use until a retest has occurred and/or facility decides to remove outlets. A notification letter will be drafted by facility to send out to parents with notification of cease of water outlets and remediation planned for water outlets or alternative. Director will send LPA a copy of the letter via email by 11/18/2025. Facility will work to begin repairs and will notify LPA when repairs are scheduled. Facility will work on scheduling for a second test of identified outlets when repairs are completed. Director will email LPA a copy of the re-test summary once completed.

Instructions for required lead testing are outlined in PIN 21-21. This PIN which contains Written Directives, have the same force and effects as the regulations contained in Title 22 of the California Code of Regulations Care Child Centers are expected to use an Environmental Laboratory Accreditation Program (ELAP), for lead testing. Accreditation from the California Environmental Laboratory Accreditation Program, known as an ELAP laboratory, is equipped to measure the amount of lead in a parts per billion (ppb) unit of measurement.

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. Please see Provider Information Notice (PIN) 20-01-CCP for more information about lead toxicity prevention

Director and School Principal received Notice of Site Visit and copy of this report with Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2025 10:15 AM - It Cannot Be Edited


Created By: Judy Laureano On 10/29/2025 at 01:09 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: ST. TIMOTHY SCHOOL PRE-K
FACILITY NUMBER: 197413960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2025
Section Cited
CCR
101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers(b) Testing results with fractional ppb readings of 0.5 ppb or greater....(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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The outlet/water faucets have been made accessible for use until a retest has occurred and/or facility decides to remove outlets. A notification of letter will be drafted by facility to send out to parents with notification of cease of water outlets and remediation planned for water outlets or alternative.
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The requirement was not met as evidence by: Lead water testing samples taken on 08/15/2025 revealed that levels of lead were beyond the allowable amount deemed by the State of California. Water Outlet “A, E and F” has Action Lead Exceedance (ALE) level 5.51 pbb.
This poses a potential health and safety risk to children in care.
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Director will send LPA a copy of the letter via email by 11/18/2025. Facility will work to begin repairs and will notify LPA when repairs are scheduled. Facility will work on scheduling for a second test of identified outlets when repairs are completed. Director will email LPA a copy of the re-test summary once completed.

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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.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Judy Laureano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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