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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750023
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:34:59 AM

Document Has Been Signed on 10/22/2024 11:34 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:LAKE LOS ANGELES ELEMENTARY SCHOOLFACILITY NUMBER:
197750023
ADMINISTRATOR/
DIRECTOR:		LUNA, JESUSFACILITY TYPE:
850
ADDRESS:16310 EAST AVENUE QTELEPHONE:
(909) 633-9496
CITY:PALMDALESTATE: CAZIP CODE:
93591
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 24DATE:
10/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Daisy Meza/Lead TeacherTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/22/2024, Licensing Program Analyst (LPA) Carol Heath met with the lead teacher, Daisy Meza, to conduct an unannounced Annual/Random inspection. LPA disclosed the purpose of the inspection and was granted entry to the facility. The center has 1 classroom (room 102) at the entrance on the right side of the elementary school hallway. There is a morning session (8:30 to 11:30 am) and an afternoon session (12:30 to 3:30 pm). Waivers are on file for shared outdoor play space and shared indoor bathrooms with the kindergarten class next door. There were 24 children present, the lead teacher and 2 assistant teachers. Incidental Medical Services (IMS) were discussed.
Physical Plant: LPA toured and inspected the preschool classroom. Furniture and equipment were checked for age appropriateness and good repair. All rooms are clean and safe. Telephone service was verified. Heating, lighting, and ventilation are adequate. There are cubbies for children's belongings labeled with their names. LPA observed age-appropriate toys and materials. Daily activities schedule was observed in each classroom. Drinking water is available in classrooms through disposable plastic cups and water jugs. A carbon monoxide detector are on the premises.
All containers used for storing solid wastes, including moveable bins, have a tight-fitting cover that is kept on; they shall be leakproof and rodent-proof.
The classroom has access to 2 bathrooms, each containing 1 toilet and 1 sink. Staff bathrooms are across the hallway in the administration office.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 10/22/2024
NARRATIVE
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 The toilets and sinks are functioning correctly. There is soap, toilet paper, and paper towels readily available. Children are inspected for illnesses as they arrive. A review of medication policy indicated that prescription medication is administered only with the parent’s permission. Daisy Meza, the school nurse, will take care of the children who need medication. The school nurse will administer medication and document the dosage, date, and time on a log. Medication is brought and locked at the center (unless the parent requests daily return). Medication is labeled correctly and stored in its original container. Medication is kept at the center until expiration and sent home with the parent for disposal. There are currently no children in care with IMS needs. The director's office has a separate area for isolating and caring for ill children. There is a mat available for ill children. An isolated toilet and sink are available for ill children in the staff restroom.
A Fire Drill/Earthquake log is posted in the classroom. The school conducted disaster drills monthly. A current Roster is available.
The outdoor: The play equipment was inspected for health, safety, cushioning material, good repair, and age appropriateness. The outdoor play equipment was inspected for health, safety, cushioning material, good repair, and age appropriateness. The area was observed to be free of debris. The play yard is through a door in the back of the classroom. The 3–4-year-olds do not use the large play structures in the sand area. The 5-year-olds have access to the entire play yard. The locked shed on the playground contains age-appropriate toys. There's a shaded area for rest. There are no bodies of water on the premises. Water fountains are operable inside and outside the classroom. LPA observed a first aid kit. LPA provided a First aid supplies list to the Director.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 10/22/2024
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The parent board was reviewed and has all the required forms posted. Fire/earthquake drills current. Sign-in and out sheets were reviewed. The Teacher-to-child ratio was observed, and staff names were recorded. Care and supervision were evaluated to determine if the children’s basic needs were met and appropriate.
Staff Records/Children's Records: Staff and children's records were reviewed. LPA verified there is at least 1 staff person present with current CPR and First Aid Training. All staff complete the Mandated Reporter training every 2 years. All staff receives Measles, Pertussis, and Influenza vaccination. All staff have requested fingerprinting associated with the facility.
LPA reviewed 5 children's records, complete with the parents' signatures.
Food Service: The facility provides breakfast for the am class and lunch for the pm class in the cafeteria down the hall on the left. Allergy lists are posted in the kitchen and classrooms. LPA observed an appropriate amount of food and snacks, and the staff prepared lunch (with gloves). Lead Water Testing: According to the lead teacher, the classroom completed the lead testing. LPA did not see the result posted in the classroom. After talking to the director, Susan Gaines, the facility is scheduling the test soon. LPA asked the director to put the “Not for drinking” and shout down the water until the test is completed. For outdoor drinking fountains, the teachers must ensure the children are not drinking.
Staff personal belongings: LPA observed staff putting their personal belongings near the children's sink. LPA advised the lead teacher, Daisy, to find an area to make the teachers' belongings inaccessible to the children.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 10/22/2024
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Immunization Requirements: §1596.7995 (a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a daycare center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
*All Licensing reports are available for review online and are considered public information. Summary: Assembly Bill 2621 added Section 1596.819 to the Health and Safety Code, requiring the Department to post certain licensing information for CCCs and FCCHs on its public internet website.
Fingerprint clearances and transfers: Before working or volunteering in a licensed childcare facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. If a fingerprint clearance has been obtained through the Department, Licensee may request a transfer of a criminal record clearance from one state-licensed facility to another using form LIC 9184
**Senate Bill AB 633 - Child Care Facilities: Parent Notification Requirements
Summary: This bill amends Health and Safety Code (HSC) sections 1596.859, 1596.8595, 1596.8895, and 1597.05 to improve the transparency of licensing records and to ensure that parents/guardians using a licensed childcare facility are aware of situations that present the greatest danger to children
**Center Director advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation (call within 24 hours and submit a written report within 7 days) and on the form LIC624. The Center reminded to review updates/regulations as well as quarterly updates on the Department website. The "Notification of Parent's Rights" poster must be posted in an area of the center accessible to parents. The information regarding new legislation with regard to exemptions and parents' rights was also discussed.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 10/22/2024
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Criminal Record Clearance - Child Care Centers Licensee [or facility representative] was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Childcare Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
Lead Testing – Child Care Centers (CCC) CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.
For the following scenarios use the below un-bolded language: • CCC COMPLETED TESTING AND IS IN THE PROCESS OF REMEDIATING LEAD EXCEEDANCES, or • CCC COMPLETED SAMPLING BUT THE TEST RESULTS ARE NOT YET AVAILABLE, or • CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE, or • CCC TESTING DEADLINE HAS NOT PAST LPA referred licensee [or facility representative] to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023
VISIT DATE: 10/22/2024
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Incidental Medical Services (IMS) - Child Care Centers IF THERE IS NO CHILD AT THE FACILITY THAT CURRENTLY NEEDS IMS, USE AS FOLLOWS: Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
MyChildCarePlan.org – Centers and Family Child Care Homes Licensee [or facility representative] was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
Notice of Site Visit - Centers and Family Child Care Homes A notice of site visit was given and must remain posted for 30 days.

Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes: (List of the deficiencies)
An exit interview was conducted, and the report was reviewed with the lead teacher, Daisy Meza.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2024 11:34 AM - It Cannot Be Edited


Created By: Carol Heath On 10/22/2024 at 10:53 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: LAKE LOS ANGELES ELEMENTARY SCHOOL
FACILITY NUMBER: 197750023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA talked to the director, Susan Gaines. According to the director, the facility is scheduleing to the lead water testing soon and the facility will have water deliver service, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The classroom will put the "No drinking" sign near the sinks (classroom and bathroom) and remind children only for washing hand. Outdoor drinking fountain will not be use for preschool children until the classroom pass the test.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


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