<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400660
Report Date: 08/28/2023
Date Signed: 10/26/2023 03:27:05 PM

Document Has Been Signed on 10/26/2023 03:27 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:YMCA OF GLB NIETO HERRERA ELEMENTARYFACILITY NUMBER:
198400660
ADMINISTRATOR:VALENCIA, DIANAFACILITY TYPE:
840
ADDRESS:1620 TEMPLE AVENUETELEPHONE:
(562) 279-1623
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 121TOTAL ENROLLED CHILDREN: 121CENSUS: 0DATE:
08/28/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Senior Program Director Michele Jansen TIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
AMENDED REPORT: Type of visit is a typo and should read Case Management Lead Testing/Exceedance

Licensing Program Analyst (LPA) Jeanette Estrada conducted an announced case management inspection on 08/28/23 LPA met with Senior Program Director Michele Janssen and Executive Director Jesse Pazdernik who guided LPA on a tour of the facility. This facility is on the premises of Long Beach Unified School District (LBUSD) Nieto Herrera Elementary. There were no children present during today's inspection. The program is set to begin operating 9/1/23. No children have been present since the facility received a provisional license on 5/23/23.

The purpose of today's inspection was to review the water lead test results received on 08/10/2023. Lead testing was conducted by LBUSD. Results show that three sources for drinking water that were tested on the facility had an action level exceedance (ALE) of lead of more than 5.5 parts per billion.
The three water sources include two drinking fountains and a water bottle filler station next to the on limits restrooms. LPA took photos of the water sources with the ALE. Water sources have been made inaccessible to children in care. Per Senior Program Director Michele Janssen, LBUSD will supply the program with bottled water until the water sources are repaired. Per Senior Program Director, LBUSD has begun repairs on the water sources and will have the water sources re-tested once repairs are complete.
A deficiency was cited to ensure that the water fountains noted will not be used as a drinking source for children in care.

The deficiency listed on the following page was 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.
A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and Appeal Rights and report were reviewed with Senior Program Director Michele Janssen.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Warren Birks
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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 2
Document Has Been Signed on 08/28/2023 11:42 AM - It Cannot Be Edited


Created By: Jeanette Estrada On 08/28/2023 at 11:14 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: YMCA OF GLB NIETO HERRERA ELEMENTARY
FACILITY NUMBER: 198400660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited

101700.3(b)(1)

1
2
3
4
5
6
7
101700.3(b)(1)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.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Water sources showing ALE have been made inaccessibe to children. Per Senior Program Director, LBUSD has begun repairs on the water sources and will provide bottled water to the program while repairs are being made. Results of re-testing will be provided to LPA by POC due date.
8
9
10
11
12
13
14
Based on record review the licensee did not ensure water sources at facility meet lead requirements. Lead test results showed that three water sources have an action level exceedance. LPA observed water sources are inaccessible to children. This poses a potential Health risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Valarie Cook
LICENSING EVALUATOR NAME:Jeanette Estrada
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2