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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400257
Report Date: 04/10/2025
Date Signed: 04/10/2025 12:12:14 PM

Document Has Been Signed on 04/10/2025 12:12 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:FAMILY OF PRAYER & PRAISE/FRUIT OF THE VINEFACILITY NUMBER:
198400257
ADMINISTRATOR/
DIRECTOR:		DON FERGUSONFACILITY TYPE:
850
ADDRESS:12204 S. SAN PEDRO ST.TELEPHONE:
(323) 305-2439
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 28TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
04/10/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Site Supervisor Christopher DorseyTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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 On 4/10/25 at 11:15AM, Licensing Program Analyst(LPA) Ashley Calderon conducted unannounced visit to conduct a Case Management Lead Testing Visit for the purpose of discussing Lead Testing Results. LPA met with Site Supervisor Christopher Dorsey. LPA disclosed the purpose of today's visit with C.Dorsey and via telephonically to Administrator Donna Cunningham.
LPA conducted a self guided tour of the facility alongside Site Supervisor Christopher Dorsey. On 3/19/25, D.Cunningham via email sent LPA Calderon Certificate of Analysis Water Testing Results. Upon review, although water testing results was conducted for lead and heavy metals, facility did not comply with Licensing Department WRITTEN DIRECTIVES FOR LEAD TESTING OF WATER IN LICENSED CHILD CARE CENTERS PURSUANT TO AB 2370 CHAPTER 676, STATUTES OF 2018 - PIN 21-21.1 CCP. Facility was unable to provide Facility Sketch indicating water valves/outlets that were tested and based on review conducted on the Lead Sampling Reporting Tool- State Water Board Website reviewed by LPA's A.Calderon and LPA Andrea Carter via telephonically on 3/19/25 there are No Sample Results listed under Infant License- 1984000928 and Day Care License- 198400257. On 3/21/25, LPA Tyler Reyes spoke with Paul Lee from Culligan Company who conducted testing less than 15.000 ug/L and did not test for lead results less than 5.5ppb. CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE, deficiency cited.
LPA Calderon observed apples in kitchen area, LPA asked Staff #1 what water source is uses to wash apples and fruits for the children. Staff #1 indicated the kitchen sink. Per D.Cunningham informed LPA Calderon food meals are delivered by Child Nutrition Express and children drink water from water dispenser by Nestle Water Delivery Company. Per D.Cunningham stated food and fruits are prepped and washed by at Child Nutrition Express before delivery and staff cut food when needed.One deficiency was cited on today's visit. A notice of site visit was provided and must be posted for 30 days. An exit interview was conducted in person with Site Supervisor Christopher Dorsey and Donna Cunningham (via telephonically). Copy of reports and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/10/2025 12:12 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Ashley Calderon On 04/10/2025 at 11:38 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY OF PRAYER & PRAISE/FRUIT OF THE VINE
FACILITY NUMBER: 198400257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
04/28/2025
Section Cited

101700.3(b)(1)

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101700.3(b)(1)
(b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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LPA Calderon provided PIN 21-21.1CCP handout to follow directive and provide documents indicating on directive to LPA Calderon by poc due date. Facility will use water dispenser from water deliever company to wash children's fruits/veggies when needed.
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This requirement was not met as evidence by:
Per phone call with Paul Lee at Water Testing Culligan Company stated testing less than 15.000 ug/L and did not test for lead results less than 5.5ppb. Results not inputted on State Water Board and No sketch provided indicating water source tested. Dept. Written Directive was not followed.
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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.
Denise Gibbs
NAME OF LICENSING PROGRAM MANAGER:
Ashley Calderon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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