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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700372
Report Date: 10/24/2022
Date Signed: 10/24/2022 12:20:13 PM

Document Has Been Signed on 10/24/2022 12:20 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:LMSVSD - BANCROFT PRESCHOOLFACILITY NUMBER:
376700372
ADMINISTRATOR:KIMBERLY LIBENGUTHFACILITY TYPE:
850
ADDRESS:8805 TYLER STREETTELEPHONE:
(619) 668-5890
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 13DATE:
10/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Lead Teacher Darcy WashkevichTIME COMPLETED:
11:00 AM
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On October 24, 2022 at 10:43 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management inspection for the purpose to provide Technical Assistance (TA) regarding required lead testing mandates. LPA advised Lead Teacher Darcy Washlevich of the meeting’s purpose and was granted facility entry.

This is a half day program which operates on a traditional school year schedule. Days and hours of operation are weekdays 8:30 AM to 11:30 AM. There is currently one (1) classroom in operation. The following ratios were observed: There were thirteen (13) children present with three (3) staff members.

Childcare centers are to test their water for lead between 01/01/2020 and 01/01/2023 and then every five (5) years after the date of the first lead testing. LPA provided Lead Teacher Darcy Washkevich with Provider Information Notice (PIN) 20-01-CCP “Required Lead Testing for Drinking Water in Licensed Child Care Centers and the Provision of the Lead Exposure Information to Parents and Guardians by All Licensed Child Care Facilities” (issued 01/10/2020), PIN 21-21-CCP “Release of the Written Directive for Lead Testing of Water in Licensed Child Care Centers per AB2370” (issued 07/28/2021) and PIN 22-06-CCP “Lead Testing in Child Care Centers – Frequently Asked Questions” (issued 02/25/2022). LPA also provided the lead teacher with the LIC 9275 – External Water Sampler Self-Certification Form and the LIC 9276 – Center Sampling Checklist Form. LPA suggested that staff review these PINs on the CCL website so they may gain access to the links and video imbedded on the online PINs. Should staff have any questions, LPA recommends they email CCCWaterTesting@dss.ca.gov.

No deficiencies were issued during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Lead Teacher Darcy Washkevich.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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