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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500936
Report Date: 09/05/2023
Date Signed: 09/05/2023 01:26:43 PM

Document Has Been Signed on 09/05/2023 01:26 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-JELLICKFACILITY NUMBER:
191500936
ADMINISTRATOR:DEBORAH SLOBOJANFACILITY TYPE:
850
ADDRESS:1400 S. JELLICKTELEPHONE:
(626) 810-0163
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 5DATE:
09/05/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Adriana LopezTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Jennifer Hua conducted an unannounced case management inspection on 9/5/2023. A COVID 19 risk assessment was conducted. LPA arrived at the facility at 12:55pm and met with lead teacher Adriana Lopez. The purpose of the visit was announced. LPA observed 5 children in care with 2 staff. Per lead teacher, there are 2 sessions for the program: AM session is State Preschool and PM session is the Headstart.

The purpose of today's inspection is to go over the water lead test results received on 08/12/2023. Results indicate that "B” water source had action level exceedance of lead. The "B" water source located in the preschool room had a lead result of 9. Per lead teacher, water fountain was capped and locked when it was tested high. The water fountain was retested on 9/1/2023 and had no deterrence. LPA observed that the water fountain is now being used. Lead teacher stated that the water fountain was flushed. Per lead teacher, ceased using the water fountain as soon as results were received and the fountain was capped and locked making it inaccessible for children and staff, but previous to that date, children had access. Children were able to access water from water pitcher or the other water fountain. LPA advised lead teacher to review PIN 21-21.1-CCP (Written Directives for Lead Testing of Water).

A deficiency was cited on attached 809D.

The deficiency listed on the following page were observed by the LPA 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 needs to be cleared to protect the children’s health & safety.

An exit interview conducted with lead teacher. Notice of Site Visit form was provided and must be posted for 30 days in an area accessible for review.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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 09/05/2023 01:26 PM - It Cannot Be Edited


Created By: Jennifer Hua On 09/05/2023 at 01:04 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-JELLICK
FACILITY NUMBER: 191500936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2023
Section Cited
CCR
101700.3(c)

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California Lead Action Level at Child Care Centers. On 8/12/23, licensee failed to maintain a lead value at or below the Action Level for water lead testing of 5.5 ppb or greater for outlet "B". Result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidenced by:
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Per lead teacher, water fountain was retested on 9/1/23 with no deterrence. Children and staff now have access to the water fountain. Licensee shall submit copy of LIC 9275, LIC 9276, facility sketch and test results to LPA
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Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink. This poses an immediate Health and Safety risk to children 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:Jennifer Hua
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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