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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416054
Report Date: 01/22/2025
Date Signed: 01/22/2025 10:28:31 AM

Document Has Been Signed on 01/22/2025 10:28 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:KIDS PARK NORTHRIDGE (SA)FACILITY NUMBER:
197416054
ADMINISTRATOR/
DIRECTOR:		ROSS, DAVIDAFACILITY TYPE:
840
ADDRESS:9056 TAMPA AVENUETELEPHONE:
(818) 998-5437
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 1DATE:
01/22/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Kayla Jimenez, Assistant DirectorTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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On 01/22/2025 at 08:45 AM, Licensing Program Analyst (LPA) Elicia Calvillo conducted an unannounced visit. LPA was greeted by Kayla Jimenez, Assistant Director and granted entry into the facility. Assistant Director guided LPA on a tour of the facility. During today’s visit there was 1 staff and 1 child present. The Purpose of today’s visit is to follow up on the ALE lead testing results and conduct an inspection.

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 10/23/2024.

Community Care Licensing was notified on 12/27/2024, that licensee water lead testing resulted in values of 5.5 parts per billion (ppb) or greater for Outlet B -Drinking Fountain. Water testing results identified with Action Level Exceedance (ALE) as defined in Written Directive section 101700.3 are not deemed safe to drink or for food preparation. Outlet "B" was reported to have an exceedance of 11.0 ppb.

During today’s visit LPA observed water outlets identified on facility sketch. LPA reviewed the outlets listed on the on the water testing documents and found that outlet B -Drinking Fountain on the facility sketch is located in the kitchen and is not in use.

LPA confirmed with Assistant Director, that Outlet B-Drinking Fountain located in the kitchen area is no longer used and is covered with a bag and blocked with a table. LPA interview with Assistant Director and staff verified children do not have access to the water source location and the Water Fountain is made inaccessible with a cover and bottled water is brought in and used for drinking water.

During visit LPA collected the following forms: LIC 9275-External Water Sampler Self-Certification, LIC 9276-Child Care Center Sampling Checklist, LIC 999-Facility Sketch (water faucets/outlets identified), and LPA photographed outlets.

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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: KIDS PARK NORTHRIDGE (SA)
FACILITY NUMBER: 197416054
VISIT DATE: 01/22/2025
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During today’s visit one Type B violation is being issued per PIN 21-21-CCP, Title 22 Regulations, Division 12, and 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.

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. For additional information see the Provider Information Notice (PIN) 21-21CCP and Lead Testing in Child Care Centers Frequently Asked Questions.

A Notice of Site Visit was given and must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to comply with posting requirement will result in an immediate civil penalty of $100.00.



Exit interview was conducted with Kayla Jimenz, Assistant Director including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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Document Has Been Signed on 01/22/2025 10:28 AM - It Cannot Be Edited


Created By: Elicia Calvillo On 01/22/2025 at 10:00 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KIDS PARK NORTHRIDGE (SA)
FACILITY NUMBER: 197416054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
100700.3(b)(1)

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(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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Per Assistant Director, Outlet "B" is no longer used by the facility and the facility uses bottled water. LPA observed water fountain not in use and a supply of bottle water.
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Based on results submitted to the Department, the facility did not comply with the section cited above in Outlet "B" was reported to have an exceedance of 1050 ppb, 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:Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


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