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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801117
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:58:19 PM

Document Has Been Signed on 05/31/2023 01:58 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PSD/BOYS & GIRLS CLUB HEAD START CENTERFACILITY NUMBER:
364801117
ADMINISTRATOR:HARRIET JAMESFACILITY TYPE:
850
ADDRESS:1180 W. 9TH STREETTELEPHONE:
(909) 381-4294
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92411
CAPACITY: 95TOTAL ENROLLED CHILDREN: 95CENSUS: 0DATE:
05/31/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Irene Solomon GlassTIME COMPLETED:
02:05 PM
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Due to required lead testing requirements, Licensing Program Analyst (LPA), Justin Giese conducted a Case Management inspection based on lead testing results received from the facility. LPA toured the facility, took census and met with Program Generalist, Irene Soloman Glass, to further discuss lead results received and measures taken for remediation of lead exceedances.

During the inspection, LPA toured and obtained photos of the following water outlets identified with lead exceedances: Outlet B (7.4 ppb) which was identified as a staff lounge hand washing sink and outlet C30 identified as staff lounge utility sink. Both outlets have been previously tested and showed exceedances, however; after re-testing, outlets B and C30 still have not been remediated.

LPA observed and obtained photos of required signage posted at the outlets for cessation of use.

Facility implemented the following plan of action until formal remediation can be completed: Facility is utilizing portable auxiliary sinks which pump bottled water from the spouts. LPA verified their functionality and observed adequate storage of 5 gallon water bottles. LPA was informed by facility maintenance staff that outlets B and C30 will have fixtures replaced or filters added. The outlets will then be re-tested for exceedances at a later date. The identified water outlets have been covered and sealed with posted signage for non-use.

Facility was previously cited for lead exceedances on 03/14/2023 and has actively applied remediation efforts. Facility will follow plan of corrections as stated on Type B deficiency cited 03/14/2023 until water outlets B and C30 give acceptable results.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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