197495060-3-13-2023-30-CC-LCLN-CPVPSK-20230313113428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197495060
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:35:36 AM

Document Has Been Signed on 03/13/2023 11:35 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	MAPLE TREE ACADEMY VENICE		FACILITY NUMBER:	197495060
ADMINISTRATOR:	ISABEL GALINDO		FACILITY TYPE:	850
ADDRESS:	11827 VENICE BLVD		TELEPHONE:	(310) 314-1111
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY: 55	TOTAL ENROLLED CHILDREN: 55	CENSUS: 8	DATE:	03/13/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	MIRANDA BATES, DIRECTOR		TIME COMPLETED:	11:45 AM

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On 03/13/2023 Licensing Program Analyst (LPA) Lisa Clayton, conducted an unannounced case management - Lead Testing Exceedance. LPA was greeted by Director Miranda Bates. LPA Clayton toured the facility and observed 8 children being care for and supervised appropriately by 2 teachers.

LPA Clayton explained the purpose of the visit. The department has received testing results, indicating a water outlet(s) has been identified with an Action Level Exceedance (ALE) in the amount of lead in water being 5.5 ppb, or greater.

During today’s inspection, LPA Clayton reviewed the following documents:

· Child Care Center Sampling Checklist Form (LIC 9276) – incomplete and unsigned

· External Water Sampler Self-Certification Form (LIC 9275) – unsigned

· Facility Sketch labeled with locations of all water outlets that were tested

Lead water testing samples collected on 03/02/2023 revealed that levels of lead were beyond allowable amount deemed by the State of California. Director Miranda was advised to complete and resubmit to licensing the incomplete documents noted above, as well as a copy of the notification to all parents via email. LPA instructed Director Miranda to post the Lead Testing Results on the parent board.

LPA observed the water outlets (8 bathroom sinks) in question, which are located in the preschool, bathrooms 1 and 2 on the first floor, and bathroom 5 on the second floor as noted on the sketch provided by the water testing company. LPA Clayton observed that none of the water outlets that returned with results in exceedance are used for drinking or the preparation of food.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MAPLE TREE ACADEMY VENICE	FACILITY NUMBER: 197495060
	VISIT DATE: 03/13/2023

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Due to the Lead water testing samples collected on 3/02/2023 which are exceed the allowable amount deemed by the State of California, per the Written Directives for Lead Testing of Water in Licensed Child Care Center, AB 2370 the following deficiency is cited (See next page 809-D).

For more information, go to the California Childhood Lead Poisoning Prevention Branch's website at www.cdph.ca.gov/programs/clppb Please see Provider Information Notice (PIN) 20-01-CCP for more information about lead toxicity prevention.

An Exit interview was conducted, and appeal right explained. A copy of this report, appeal rights, and Notice of Site Visit provided to Miranda Bates, Director.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2023 11:35 AM - It Cannot Be Edited

Created By: Lisa Clayton On 03/13/2023 at 11:00 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: MAPLE TREE ACADEMY VENICE	FACILITY NUMBER: 197495060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2023 Section Cited 101700.3(b)(1)	1 2 3 4 5 6 7	101700.3(b)(1) California Lead Action at Child Care Centers (b)Testing results with fractional ppb readings....(1) A result of 5.5ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidence by the Action Level Exceedance results revealed that levels of lead were beyond allowable amount deemed by the State of California, if not corrected this poses a potential Health and Safety or Personal Rights risk to children in care.	1 2 3 4 5 6 7	The Director and staff will ensure that the faucets in the children’s bathroom are used solely for the intended purpose of handwashing only.
	8 9 10 11 12 13 14	This requirement was not met as evidence by the Action Level Exceedance results revealed that levels of lead were beyond allowable amount deemed by the State of California and if not corrected this poses a potential Health and Safety or Personal Rights risk to children in care.	8 9 10 11 12 13 14	Director will notifiy parents of water testing results and post the results on the parent board, provide LPA with a copy of the parent notification no later than 03/15/2023. Director will resubmit completed LIC 9275 and LIC 9276 immediately upon receipt.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Mary Ruiz

LICENSING EVALUATOR NAME:

Lisa Clayton

LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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