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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801117
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:28:53 PM

Document Has Been Signed on 11/29/2023 02:28 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: 23DATE:
11/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Natalia MundoTIME COMPLETED:
02:35 PM
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Due to required lead testing requirements, Licensing Program Analyst (LPA), Justin Giese conducted a Case Management POC inspection based on lead testing results received from the facility. LPA toured the facility, took census and met with acting Site Supervisor, Natalia Mundo to further discuss lead results received.

Facility was previously cited for exceedances at the following outlests: Outlet A (8.2 ppb) which was identified as facility kitchen prep sink and outlet B identified as staff lounge hand washing sink. Outlet B (7.4 ppb) which was identified as a staff lounge hand washing sink and outlet C30 identified as staff lounge utility sink.

On 10/28/2023 Outlets A, B, and C30 were retested, and passed with the following results:

Outlet A: 1.100ppb
Outlet B: 4.700ppb
Outlet C30: 1.300ppb

LPA Giese toured the facility and observed outlets A,B, and C30 to be in use. All pending deficiencies will be cleared as a result of this visit.

Exit interview was conducted and this report was reviewed with Site Supervisor, Natalia Mundo.

Notice of Site Visit was issued and must remain posted for the next 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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