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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600812
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:15:31 PM

Document Has Been Signed on 09/09/2022 03:15 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PRINCE OF PEACE LUTHERAN NURSERY SCHOOLFACILITY NUMBER:
300600812
ADMINISTRATOR:MILLA, MARIAFACILITY TYPE:
850
ADDRESS:1421 WEST BALL ROADTELEPHONE:
(714) 774-0993
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 9DATE:
09/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maria Milla - DirectorTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Odom and Castanon conducted an unannounced Case Management visit. LPA met with Director Maria Milla to discuss the Lead Sampling Testing conducted on 08/15/22. LPA Odom ensured the Lead Sample Report is posted. Licensee was advised on 09/08/22 the Lead Sample Report was to be posted; LPA confirmed the Licensee posted the Sample Report.

Director stated the outlets with high levels of Lead is inoperable. Outlet A is a drinking fountain in Rm #6 that has been closed off by shutting off the water outlet. Outlet B is a drinking fountain in Rm #5 that has been closed off by shutting off the water outlet. Outlet C is a drinking fountain in Rm #3 that has been closed off by shutting off the water outlet. Outlet E is a drinking fountain in Rm #2 that has been closed off by shutting off the water outlet. Director stated the board of education have decided to permanently remove the outlet. Source of drinking water is children’s water bottles brought from home and refilled by staff using pitchers with filtered water from the water dispenser located in the kitchen.

Based on LPAs record reviews the following violation was observed and is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 3, Section 101700.3 California Lead Action Level at Child Care Centers is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the Director Maria Milla. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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 09/09/2022 03:15 PM - It Cannot Be Edited


Created By: Carmen Odom On 09/09/2022 at 02:49 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PRINCE OF PEACE LUTHERAN NURSERY SCHOOL
FACILITY NUMBER: 300600812

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

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101700.3 California Lead Action Level at Child Care Centers (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. This requirement was not met as evidenced by:
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Director posted the lead sampling test results. Director shut off the outlets in Rm 2,3,5,and 6. Director is utilizing other source of water by children bring their water bottles and filtered water dispensor. Director stated they plan to permanently remove the outlets. Director to send LPA plan/resolution by poc date 9/13/22.
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Based on facility Lead sampling tests it was discovered that the drinking fountain outlets in Rm 2, Rm 3, Rm 5, and Rm 6 had high level of lead. This poses an immediate/potential risk to the health of 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:Judy Hanson
LICENSING EVALUATOR NAME:Carmen Odom
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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