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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370512
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:42:06 PM

Document Has Been Signed on 03/02/2023 01:42 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:CENTRALIA STATE PRESCHOOL AT SAN MARINOFACILITY NUMBER:
304370512
ADMINISTRATOR:MILES, DEBORAHFACILITY TYPE:
850
ADDRESS:6215 SAN ROLANDO WAY #3 & 4TELEPHONE:
(714) 228-3453
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 50TOTAL ENROLLED CHILDREN: 49CENSUS: 21DATE:
03/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jessica Ramirez, Pre School TeacherTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) P. Rivas conducted an unannounced Case Management visit. LPA met with Preschool Teacher, Jessica Ramirez to discuss the Lead Sampling Testing conducted on 01/04/23. 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 01/04/23 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. On 03/01/23 Site Director was advised that the Lead Sample Report was to be posted.

This facility is composed of rooms 3 and 4. Outlet A is a drinking fountain inside classroom #3. Upon arrival LPA viewed drinking fountain to be inaccessible via a sign taped over faucet.

Teacher stated the Outlet A with ALE of (12.3 ppb) had been made inoperable pending remediation. LPA viewed test result were posted. The teacher stated that the drinking faucets were not in use since 2020 (due to Covid-19). Furthermore, teacher Ramirez indicated room #3 was not in use since Covid-19 in 2020. The children bring in their own bottles of water and or water is provided by facility if children forget water.
LPA verified that the test sample results were posted and verified documentation of the action that the facility had taken.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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: CENTRALIA STATE PRESCHOOL AT SAN MARINO
FACILITY NUMBER: 304370512
VISIT DATE: 03/02/2023
NARRATIVE
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(Page 2 of Report)

Based on LPA's observation, interview with Jessica Ramirez Preschool Teacher , review of facility's sketch and documentation regarding action taken to fix the identified outlets, 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.


Exit interview conducted and report was reviewed with Jessica RAmirez Preschool Teacher.

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 do so will result in a civil penalties of $100.00

Appeal Rights and deficiency were explained. Jessica RAmirez, Preschool 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 above.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2023 01:42 PM - It Cannot Be Edited


Created By: Pat Rivas On 03/02/2023 at 01:23 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: CENTRALIA STATE PRESCHOOL AT SAN MARINO
FACILITY NUMBER: 304370512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2023
Section Cited

101700.3(b)1

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101700.3 California Lead Action Level at Child Care Centers (b) Testing results...comparing to the Action
Level. (1) A result with values of 5.5 part per billion or greater shall be deemed an Action Level Exceedance. This requirement
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Staff made outlets inaccessible and will repair/replace outlets by plan of correction date Proof to be provided to LPA Rivas by plan of correction date.
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was not met evidenced by:Lab report water analysis from Outlet A (12.3 ppb) taken on 01/04/23 indicated levels of lead in exceedance. This poses a potential risk to the health, safety and personal rights 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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
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