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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018931
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:55:38 PM

Document Has Been Signed on 03/12/2024 01:55 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CONCORDIA LUTHERAN KING'S CLUBFACILITY NUMBER:
198018931
ADMINISTRATOR:SUSAN JENNINGSFACILITY TYPE:
840
ADDRESS:13633 183RD ST.TELEPHONE:
5629262491
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 30TOTAL ENROLLED CHILDREN: 7CENSUS: 0DATE:
03/12/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Elizabeth Medina TIME COMPLETED:
01:30 PM
NARRATIVE
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About 12:20PM, Licensing Program Analysts (LPAs) T. Tran and C. Kam conduct an unannounced visit at the above licensed facility for a case management inspection for Lead. Upon arrival, LPAs met with Elizabeth Medina, and we toured the facility. LPAs did not observe any school age children at this time.

The purpose of today's inspection was to go over the water lead test results received on 12/16/22. Results show that thee water sources had action level exceedance of lead. The water fountain located in schoolage room 3 and 23. And preschool room 7 had a lead result over 5.5 ppb. Record reviewed indicates as of 7/22/23 all three faucets were had been replaced. A deficiency was cited to ensure that the water faucets noted will not be used as a drinking source or food preparation source for the children.

The deficiency listed on the following page were observed by the LPA and is being cited in accordance with 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. LPA obtained the correction record, plan of correction has been cleared during today's visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Elizabeth Medina.

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 03/12/2024 01:55 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 03/12/2024 at 01:31 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: CONCORDIA LUTHERAN KING'S CLUB
FACILITY NUMBER: 198018931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2024
Section Cited
CCR
101700.3(b)(1)–(b)

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Result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance This requirement was not met as evidence by record review. Lead test results showed that two water sources had an action level exceedance.
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On 7/22/23, facility had provided 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. All water souces with lead exceedance had been replaced.
POC corrected during today's visit.

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LPA observed the water faucets in class 3, 23 and preschool class 7 had been replaced. 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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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