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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500340
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:47:37 PM

Document Has Been Signed on 11/01/2023 02:47 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:OPTIONS-STATE PRESCHOOL-NORTHAMFACILITY NUMBER:
191500340
ADMINISTRATOR:DEBORAH SLOBOJANFACILITY TYPE:
850
ADDRESS:423 SHIPMANTELEPHONE:
(818) 913-1325
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 48TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/01/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sylvia Garcia/Joel UristaTIME COMPLETED:
03:00 PM
NARRATIVE
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On 11/1/2023 Licensing Program Analysts (LPAs) Carolyn Tuba and Stephanie Li conducted an unannounced case management inspection. A COVID 19 risk assessment was conducted. LPAs arrived at the facility at 1:30 pm and met with Site Director/Lead Teacher, Sylvia Garcia and Maintenance Lead Tech, Joel Urista arrived shortly after. LPAs observed no children in care due to dismissal time had occurred at 12:00 PM.

The purpose of today's inspection is to go over the water lead test results received on 08/22/2023. Results indicate that fixture “A” drinking fountain water source had action level exceedance of lead. The "A" drinking fountain water source located in the preschool classroom had a lead result of 6.3. During the visit, the Maintenance Lead Tech had stated that the drinking fountain has been removed and capped off. LPAs took photo. According to Site Director/Lead Teacher children are provided water from the kitchen sink that has been tested and there are no lead exceedances from that water source. LPA, Carolyn Tuba received all documentation, including facility sketch, LIC9276, LIC9275, photos and test results from the Andrea Butler, Facilities Administrative Coordinator prior to visit.

A deficiency was cited on attached 809D.

The deficiency listed on the following page were informed to LPAs and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that is being cited

A notice of site visit was given to Site Director/Lead Teacher and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Site Director/Lead Teacher, Sylvia Garcia.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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 11/01/2023 02:47 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 11/01/2023 at 02:20 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OPTIONS-STATE PRESCHOOL-NORTHAM
FACILITY NUMBER: 191500340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3(b)(1) California Lead Action Level at Child Care Centers. (b) Testing results with...readings of 0.5 ppb or greater..., before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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LPAs observed that the water fountain has been capped off and is no longer available to use.
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This requirement is not met as evidenced by: Based on testing results provided by the facility with an Action Level Exceedance (ALE) which poses/posed a potential health, safety or personal rights risk to persons 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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
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