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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011011
Report Date: 09/22/2022
Date Signed: 09/22/2022 05:02:15 PM

Document Has Been Signed on 09/22/2022 05:02 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:YOUNG HORIZON-GRISHAM SITEFACILITY NUMBER:
198011011
ADMINISTRATOR:TANDOC, NICETAFACILITY TYPE:
830
ADDRESS:11 W. 49TH STREETTELEPHONE:
(562) 984-3801
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 24TOTAL ENROLLED CHILDREN: 20CENSUS: 14DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Director Chhum KenTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Randy Derraco conducted an unannounced case management inspection on 09/22/20. LPA arrived at the facility at 12:30 PM and met with Director Chhum Ken , who guided LPA on a tour of the facility. There were 14 children and 13 staff present during the inspection

The purpose of tody's inspection was to go over the water lead test results, sample date 07/06/22. Results show that one water source had action level exceedance of lead. The water fountain located next to the kitchen (sample site location D) had a lead result of 8.5. LPA observed that the water fountain was covered with a plastic bag to make it inaccessible to children in care. Director states that water fountain has been inaccessible for approximately 2 years, due to Covid-19. Director states that drinking water is provided to children in care via water filtration system located in the kitchen / food prep area. Water jugs are filled for each classroom and for the outdoor play area using the water filtration system. Menu food items are prepared at a separate location and delivered to the facility where it is portioned out to the children in care. LPA R. Derraco took pictures of the water fountain during the inspection. A deficiency was cited to ensure that the water fountain will not be used as a drinking source.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulation Title 22. Please see attached LIC 809-D. The deficiency that is being cited needs to be cleared to protect the children's health and safety.

Exit interview conducted, appeal rights provided and report was reviewed with Director Chhum Ken. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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Document Has Been Signed on 09/22/2022 05:02 PM - It Cannot Be Edited


Created By: Randy Derraco On 09/22/2022 at 04:28 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: YOUNG HORIZON-GRISHAM SITE
FACILITY NUMBER: 198011011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited
CCR
101700.3(b)(1)

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(b)Testing results with fraction ppb readings of .5 ppb or greater shall be rounded up to the neares whole number , before comparing to the Action Level

(1) A result with values 5.5 ppb or greater shall be deemed an Action Level Exceedence
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The facility will provide a written statement on their plan to continue to ensure that the water sources will not be used as a drinking or food preparation source by the POC date of 10/13/22
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This requirement was not met as evidence by record review. Lead test results showed that one water source had an action level exceedance. LPA Derraco observed the water fountain to be made inaccessible with a plastic bag.
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This is a potential risk to the health and safety of the children 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:Trevino Cochran
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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