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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840745
Report Date: 02/21/2023
Date Signed: 02/21/2023 11:36:21 AM

Document Has Been Signed on 02/21/2023 11:36 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:FSA-OLIVEWOOD CDCFACILITY NUMBER:
334840745
ADMINISTRATOR:LACY HUGHESFACILITY TYPE:
850
ADDRESS:23268 OLIVEWOOD PLAZA DR.TELEPHONE:
(951) 924-6100
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 144TOTAL ENROLLED CHILDREN: 144CENSUS: 67DATE:
02/21/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lacy HughesTIME COMPLETED:
11:45 AM
NARRATIVE
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On 02/21/23 at 09:15 AM, Licensing Program Analysts (LPAs) Sumayya Habeebulla and Jessica Rubio, conducted a follow up Case Management visit in response to information received from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). LPAs met with Director, Lacy Hughes who was informed of the reason for the visit.

Assembly Bill 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers constructed before January 1, 2010, to test their drinking and cooking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first lead testing. LPA observed on the report provided by the SWRCB the FAUCET K, Faucet M, Faucet N, and Faucet A30 identified as having high levels of lead.

The faucet A30 is located in the Kitchen and has been replaced and retested. Faucet K is located inside Room 5 and has also been replaced and retested. Faucet M and N are outdoors and have been permanently removed and capped.

See LIC 809D for cited deficiency in accordance with the California Code of Regulations Title 22, Division 12 written directives.

An exit interview was conducted with the Director Lacy Hughes. A copy of this report, appeal rights and a Notice of Site Visit was issued.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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 02/21/2023 11:36 AM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 02/21/2023 at 11:19 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: FSA-OLIVEWOOD CDC
FACILITY NUMBER: 334840745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2023
Section Cited

101700.3(b)(1)

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California Lead Action Level at Child Care Centers(b) Testing results...ppb readings of 0.5 ppb or greater...(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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Facility has removed and capped faucets M and N and replaced and retested Faucet A30 and Faucet K. LPA has received results showing that there is no longer an exceedance.
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LPA received the facility's water testing results for Faucet K, M, N and A30 with an Action Level Exceedance higher than the allowable limit.
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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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023


LIC809 (FAS) - (06/04)
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