304370080-2-15-2023-06-CC-PRIS-CP3MNX-20230215084613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370080
Report Date: 02/15/2023
Date Signed: 02/15/2023 08:47:28 AM

Document Has Been Signed on 02/15/2023 08:47 AM - 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:	ANAHEIM ELEMENTARY SCHOOL DISTRICT ROSS		FACILITY NUMBER:	304370080
ADMINISTRATOR:	JELINEK, VIVIANA		FACILITY TYPE:	850
ADDRESS:	535 S. WALNUT STREET		TELEPHONE:	(714) 517-8989
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 24	CENSUS: 0	DATE:	02/15/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Judy Acevedo, Teacher		TIME COMPLETED:	09:15 AM

NARRATIVE

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Licensing Program Analysts (LPA) Patricia Rivas and Araceli Bootorabi conducted a case management visit. LPA met with Teacher Judy Acevedo to discuss the Lead Sampling Testing conducted on 12/20/2022. Lynda Durand Early Childhood Coordinator was advised on 02/08/23 to post the Lead Sample Report . Facility staff had previously provided LPA copies of all documentation requested regarding Lead; LIC 999 Facility Sketch, LIC 9275 and LIC 9276. LPAs confirmed that Coordinator had posted the Lead Sample Report. Census was taken Total of 2 Teachers and 0 children observed in Room K1.
A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Facility was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
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 12/20/2022 failed allowable limit for lead. The purpose of today’s visit is to follow up lead testing results of Action Level Exceedance (ALE) on yard fountains(bubblers) Outlets B (ALE 19) and fountain inside classroom (ALE 250). Teacher advised that faucets have not been used since Covid-19 in 2020 and children bring their own bottles and facility also provides water.

Instructions for required lead testing are outlined in PIN 21-21.1-CCP (Supersedes 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.

cont. on page 2

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: ANAHEIM ELEMENTARY SCHOOL DISTRICT ROSS	FACILITY NUMBER: 304370080
	VISIT DATE: 02/15/2023

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LPAs observed outlets A & B were made inoperable via a bag over outlets and a do not use sign .
Teacher reports children bring their own water,

Based on LPA's observation and interview with Teacher Judy Acevedo 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.

An exit interview was conducted with Teacher Judy Acevedo . Appeal Rights were explained. The teacher 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.

The Notice of Site Visit was given and discussed it must be posted as required by H & S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2023 08:47 AM - It Cannot Be Edited

Created By: Pat Rivas On 02/15/2023 at 08:10 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: ANAHEIM ELEMENTARY SCHOOL DISTRICT ROSS	FACILITY NUMBER: 304370080
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2023 Section Cited 101700.3(b)(1)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	During visit, LPA confirmed lead results were posted, and lead documents were submitted. teacher reports faucets were
	8 9 10 11 12 13 14	This requirement is not met evidenced by record review of the lab report analysis as reported to Dept from Outlets A(ALE250) & B(ALE19) taken on 12/20/2022. Results indicated levels of lead in exceedance at 5.6 This poses a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14	replaced during winter break , currently conducting flushing & awaiting retesting ; after retesting if ale levesl are still in exceedance director will remove, replace or repair outlet A and B and will submit plan of correction by 03/15/2023
	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:

Rina Lopez

LICENSING EVALUATOR NAME:

Pat Rivas

LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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