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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270808
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:07:39 PM

Document Has Been Signed on 09/16/2022 03:07 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:CYPRESS LEARNING TREEFACILITY NUMBER:
304270808
ADMINISTRATOR:ERICKSON, MANDYFACILITY TYPE:
850
ADDRESS:5417 BISHOP STREETTELEPHONE:
(714) 527-2744
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 84TOTAL ENROLLED CHILDREN: 84CENSUS: 27DATE:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mandy Erickson, directorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Dean Valencia conducted an unannounced Case Management Inspection, met with director Mandy Erickson to discuss the Lead Sampling testing conducted. A physical plant walk through was conducted and census of staff/children was taken in individual classrooms. During the inspection there were 29 children present and 5 staff. During the inspection, LPA Valencia ensured the Lead Sample Report is posted.

Director stated that they single faucet that reported exceedance lead levels has since been replaced. The supply line to this faucet replaced as well. Director stated that they are in the process of a flushing of this line and faucet line, to then proceed with a second lead test. Once the second lead test is completed a correction and test result will be submitted to LPA.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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 09/16/2022 03:07 PM - It Cannot Be Edited


Created By: Dean Valencia On 09/16/2022 at 09:35 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CYPRESS LEARNING TREE
FACILITY NUMBER: 304270808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited

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.
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The director has taken steps to fix the faucet and return the water line to levels of lead below 5.5 ppb. The correction for this will be subnmitted to LPA by 10/14/22.
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The above was not met as evidenced by:
The facility registered a single faucet in the facility with lead levels exceeding 5.5ppb.
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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:Dean Valencia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


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