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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371420
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:14:44 PM

Document Has Been Signed on 09/07/2023 03:14 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MAGICAL STAR MONTESSORI-PRESCHOOLFACILITY NUMBER:
304371420
ADMINISTRATOR:VITHANAGE, IRA DAYANIFACILITY TYPE:
850
ADDRESS:1636 WEST CATHERINE DRIVETELEPHONE:
(714) 696-1241
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 47TOTAL ENROLLED CHILDREN: 47CENSUS: 16DATE:
09/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Director Dayani VithanageTIME COMPLETED:
03:30 PM
NARRATIVE
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(page 1)
Licensing Program Analyst Giselle Lucero conducted an unannounced Case Management visit. LPA met with Director Dayani Vithanage, to discuss the Lead Sampling Testing conducted on 08/15/2023. Director was advised on 08/31/2023 that the Lead Sample Report needs to be posted. LPA confirmed Director had posted the Lead Sample Report.

Director stated the outlet with high levels of Lead is inoperable. Outlet B is a drinking fountain in a room located by the front entrance permanently closed off, they have made the drinking fountain that tested with high levels of Lead inoperable. Source of drinking water is children’s water bottles brought from home and refilled by the filtered kitchen faucet that tested negative for Lead.

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 Director Dayani Vithanage. 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.

End of Report.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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Document Has Been Signed on 09/07/2023 03:14 PM - It Cannot Be Edited


Created By: Giselle Lucero On 09/07/2023 at 02:38 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: MAGICAL STAR MONTESSORI-PRESCHOOL
FACILITY NUMBER: 304371420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2023
Section Cited

101700.3(b)(1)

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Division 12, Chapter 1, Subchapter 5
101700.3 California Lead Action Level at Child Care Centers (b) Testing... 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 permanently closed outlet B. Director is utilizing other source of water by children bringing their own water bottles and are being refilled by the filtered kitchen faucet that tested negative for Lead.
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Based on facility Lead sampling tests it was discovered that outlet B had a high level of lead. This poses a 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:Giselle Lucero
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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