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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270808
Report Date: 12/19/2022
Date Signed: 12/19/2022 03:15:11 PM

Document Has Been Signed on 12/19/2022 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: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: 29DATE:
12/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Mandy Erickson, DirectorTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mila Quinto conducted a case management visit. LPA met with Director Mandy Erickson to discuss the Lead Sampling Testing conducted on 10/15/2022. Director was advised on 12/15/2022 that the Lead Sample Report was to be posted. Director provided LPA copies of all documentation requested regarding Lead; LIC 999 Facility Sketch, LIC 9275 and LIC 9276. LPA confirmed that Director had posted the Lead Sample Report during visit on 12/19/2022.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires all licensed Child Care Centers (CCC’s) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every five years after the date of the first test. Community Care Licensing was notified that lead water testing conducted at the facility on 09/2722 failed allowable limit for lead. The purpose of today’s visit is to follow up lead testing results of Action Level Exceedance (ALE).

Instructions for required lead testing are outlined in PIN 21-21-CCP. This PIN which contains Written Directives, have the same force and effects as the regulations contained in Title 22 of the California Code of Regulations.

Child Care Centers are expected to use an Environmental Laboratory Accreditation Program (ELAP), for lead testing. Accreditation from the California Environmental Laboratory Accreditation Program, known as an ELAP laboratory, is equipped to measure the amount of lead in parts per billion (ppb) unit of measurement.

LPA observed outlet L in Room 4 were made inoperable via large trash bag with an “Out of Service” sign on top of the covered sink. This outlet was only used to wash hands.



Based on LPA's observation and interview with Director, the following violation was observed and is being cited in accordance with Written Directives Section 101700.3 (b)(1) California Lead Action Level at Child Care Centers, is being cited on the attached LIC 809D.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TREE
FACILITY NUMBER: 304270808
VISIT DATE: 12/19/2022
NARRATIVE
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Exit interview conducted and report was reviewed with Administrator Tay Armstrong. A notice of site visit was given and must remain posted for 30 days. Appeal Rights and deficiency were explained. The Director was provided a copy of appeal rights (LIC 9058) 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: Patricia Magana
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2022 03:15 PM - It Cannot Be Edited


Created By: Mila Quinto On 12/19/2022 at 02:46 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: CYPRESS LEARNING TREE
FACILITY NUMBER: 304270808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited

101700.3(b)(1)

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101700.3 (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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During visit, LPA confirmed lead results were posted, and lead documents were submitted. Director will remove, replace or repair outlet L and will submit plan of correction by 1/6/23.
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This requirement is not met evidenced by record review of the lab report analysis from Outlet L taken on 10/15/2022. Results indicated levels of lead in exceedance. This poses a potential risk to the health and safety 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:Patricia Magana
LICENSING EVALUATOR NAME:Mila Quinto
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022


LIC809 (FAS) - (06/04)
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