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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197416902
Report Date: 12/02/2022
Date Signed: 12/02/2022 01:47:25 PM

Document Has Been Signed on 12/02/2022 01:47 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:99TH STREET ELEMENTARY SCHOOL CSPP/HEAD STARTFACILITY NUMBER:
197416902
ADMINISTRATOR:MARISSA BORDONFACILITY TYPE:
850
ADDRESS:9900 S.WADSWORTH AVE.RMS 12,13TELEPHONE:
(323) 564-2677
CITY:LOS ANGELESSTATE: CAZIP CODE:
90002
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 3DATE:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Marissa Bordon, PrincipalTIME COMPLETED:
01:55 PM
NARRATIVE
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On December 2, 2022, at 12:50 p.m., Licensing Program Analyst (LPA) Denise Gibbs conducted an unannounced case management inspection and met with Principal Marissa Bordon. LPA disclosed the purpose of the inspection and was granted entry into the facility.

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

The purpose of today's inspection was to discuss the water lead test results. Results show that two water sources have action level exceedance (ALE) of lead. The drinking fountain located in the classroom and a drinking fountain in the outdoor play yard had a lead exceedance of 29.3 and 32.8.

At 1:00 p.m. LPA observed and tested water sources with ALE. Water sources were observed to be shut off and inaccessible to children. Per Staff, families are asked to bring water bottles from home. LPA observed two out of the three children had water bottles. LPA did not observe any other source of water readily available for children to fill empty water bottles or a way to provide children with water if they do not bring water from home. LAUSD Lead exceedance team has begun to correct the ALE by shutting off the water and is in the process of installing filters to the affected water sources. LAUSD facility maintenance has not given a date to begin work. A deficiency was cited to ensure that the water sources with the exceedance will not be used as a drinking source or food preparation source for the children. A deficiency will also be cited to ensure non-contaminated water is made readily available both indoors and outdoors.

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 ----------------------PAGE 1
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902
VISIT DATE: 12/02/2022
NARRATIVE
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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.

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, Marissa Bordon, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Denise Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2022 01:47 PM - It Cannot Be Edited


Created By: Denise Gibbs On 12/02/2022 at 01:23 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: 99TH STREET ELEMENTARY SCHOOL CSPP/HEAD START
FACILITY NUMBER: 197416902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
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 sources showing ALE have been shut off and children do not have access. Per Principal, facility maintenance will be adding filters to the water sources 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 two drinking water sources have an action level exceedance. LPA observed water sources are inaccessible to children.
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Type B
12/07/2022
Section Cited
CCR101639.2(c)

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101639.2(c) Drinking Water
(c) Drinking water from a non contaminating fixture or container shall be readily available to children both indoors and in the outdoor activity area.
This requirement was not met as evidence by:
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Per Principal, she will order bottled water from the district and provide the children with water. Principal will send LPA a picture of water bottles in the classroom by POC date 12/7/22.
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Based on record review the licensee did not ensure water was made readily available to children both indoors and outdoors. 2 out of 3 children were observed to have water bottles from home.
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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: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
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