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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021184
Report Date: 02/27/2024
Date Signed: 02/27/2024 02:45:38 PM

Document Has Been Signed on 02/27/2024 02:45 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 CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:EVERGREEN CHILD CARE CENTERFACILITY NUMBER:
198021184
ADMINISTRATOR:SASHA DUARTEFACILITY TYPE:
850
ADDRESS:211 S. EVERGREEN AVENUETELEPHONE:
(323) 263-2816
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 46TOTAL ENROLLED CHILDREN: 46CENSUS: 0DATE:
02/27/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Sasha Duarte, Director TIME COMPLETED:
02:45 PM
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On 2/27/24 Licensing Program Analysts (LPA) Staicy Perry conducted an unannounced case management inspection. A COVID 19 risk assessment was conducted. LPA arrived at the facility at 1:31 pm and met with Director, Sasha Duarte. LPA observed 0 children with 1 staff (Director) in care. Facility operates M-F from 9:00am-12:00pm.

Analyst reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility Director during the inspection. Per AB 2370, all CCCs that are in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

On 08/02/2023, the Department received notification from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 7.27.2023. Drinking faucet located in Classroom A reported with 5.5 ppb or greater lead exceedance level were as follows:

· During this inspection, water outlet “G” located in Classroom A, was observed to be permanently removed. LPA took a photo of the Water Drinking Facet.

The purpose of today's inspection is to go over the water lead test results received on 08/02/2023. Results indicate that fixture “G” Drinking faucet located in Classroom A had action level exceedance of lead. The "G" Drinking faucet located in Classroom A had a lead result of 9.480. During the visit, the Director Sasha stated that the Drinking faucet located in Classroom A was tested on 7/27/23.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Staicy Perry
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN CHILD CARE CENTER
FACILITY NUMBER: 198021184
VISIT DATE: 02/27/2024
NARRATIVE
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Once Director received results Director immediately ceased the use of that drinking faucet located in Classroom A. Plumbers and DWP were contacted to inspect and identify what needed to be completed. During the time it took to get the facet taken out, Director Sasha stated that water source was covered with a purple bag and a notice was posted indicating "Do Not Touch" and water was capped off. Children are provided bottled water and made accessible to the children in each classroom in an Igloo blue container. Director stated that a retest is not being done due to the facet being permanently removed. LPA did observe blue Igloo water jug and small cups for the children and were seen to be accessible.

LPA, Staicy Perry received all documentation, including facility sketch, LIC9276, LIC9275, photos and test results from Sasha Duarte during today’s visit. LPA Perry informed Director Sasha to sign a Declaration (LIC855). Director stated that if and ever in the future the drinking faucet in Classroom A is to be used, a retest will be conducted and Director will notify the department prior to use.

A deficiency was cited on attached 809D. The deficiency listed on the following page were observed by the LPAs 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.

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

Exit interview conducted and report was reviewed with Director Sasha Duarte.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Staicy Perry
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2024 02:45 PM - It Cannot Be Edited


Created By: Staicy Perry On 02/27/2024 at 02:16 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN CHILD CARE CENTER
FACILITY NUMBER: 198021184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/27/2024
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1) California Lead Action Level at Child Care Centers. (b) Testing results with...readings of 0.5 ppb or greater... (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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LPA observed that the Water Drinking Facet is permanently removed and capped off and is no longer available to use. LPA took photos of the Water Drinking Facet "G" in Classroom A.
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This requirement is not met as evidenced by: Based on testing results provided by the facility with an Action Level Exceedance (ALE) which poses/posed a potential health, safety or personal rights risk to persons 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:Claudia Guangorena
LICENSING EVALUATOR NAME:Staicy Perry
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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