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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197415233
Report Date: 11/30/2022
Date Signed: 11/30/2022 12:24:16 PM

Document Has Been Signed on 11/30/2022 12:24 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:RUSSELL ELEMENTARY SCHOOLFACILITY NUMBER:
197415233
ADMINISTRATOR:JOHN P. SAYERSFACILITY TYPE:
850
ADDRESS:1263 EAST FIRESTONE BLVD. #20TELEPHONE:
(323) 582-7247
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 21TOTAL ENROLLED CHILDREN: 21CENSUS: DATE:
11/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:John Sayers, PrincipalTIME COMPLETED:
12:30 PM
NARRATIVE
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On November 30, 2022, at 11:45 a.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection and met with Principal John Sayers. LPA disclosed the purpose of the inspection and was granted entry into the facility by Principal.

There were 19 children and three staff present during the inspection.

The purpose of today's inspection was to discuss the water lead test results. Results show that one water source has action level exceedance (ALE) of lead. The drinking fountain located inside the classroom had a lead exceedance of 288.12.

At 11:55 a.m. LPA observed and took pictures of the water source with ALE. Water source was observed to be inaccessible to children. LPA observed that water is turned off. Per staff, water is made readily available to children via water bottles brought from home and water bottles provided at the facility. LPA observed water bottles. Drinking fountain outdoors is operable. LAUSD Lead exceedance team has begun to correct the ALE and is in the process of installing filters to the affected water source. LAUSD facility maintenance has not given a date to begin work. A deficiency was cited to ensure that the water faucets with the exceedance will not be used as a drinking source or food preparation source for the children.

Per Principal, all meals are prepackaged and delivered daily by Los Angeles Unified School District (LAUSD). Food is not cook or prepared at the facility.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that is being cited needs to be cleared to protect the children’s health & safety.
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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/30/2022 12:24 PM - It Cannot Be Edited


Created By: Denise Gibbs On 11/30/2022 at 10:34 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1)
(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.
This requirement was not met as evidence by:
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Water source showing ALE have been shut off and children do not have access. Per Principal, facility maintenance will be adding filters to the water source in order to correct the lead exceedance. Maintenance date is still being determined. Principal or Lead Exceedance team will send LPA an email confirming correction by POC date 12/16/22.
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Based on record review the licensee did not ensure water sources at facility meet lead requirements. Lead test results showed that one water source has an action level exceedance. LPA observed water source is inaccessible to children.
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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:Trevino Cochran
LICENSING EVALUATOR NAME:Denise Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUSSELL ELEMENTARY SCHOOL
FACILITY NUMBER: 197415233
VISIT DATE: 11/30/2022
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days.

Exit interview was conducted and Plans of Corrections were reviewed and developed with Principal. A copy of this report and appeal rights were discussed and left with Principal, John Sayers, whose signature on this form confirm receipt of these documents.

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SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3