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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597736
Report Date: 04/12/2024
Date Signed: 04/12/2024 10:30:16 AM

Document Has Been Signed on 04/12/2024 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CARVER HEAD START/STATE PRESCHOOLFACILITY NUMBER:
191597736
ADMINISTRATOR:ROSELIA GOMEZFACILITY TYPE:
850
ADDRESS:19200 ELY STREETTELEPHONE:
(562) 229-7933
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 38TOTAL ENROLLED CHILDREN: 27CENSUS: 25DATE:
04/12/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jacqueline RuvalcabaTIME COMPLETED:
11:00 AM
NARRATIVE
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On 04/12/2024, about 9:00AM, Licensing Program Analysts (LPAs) T. Tran and P. Bowden conduct an unannounced case management for Lead at the above licensed facility. Upon arrival, LPA met with Lead Teacher, Jacqueline Ruvalcaba and we toured the facility. LPAs observed proper care and supervision.

The purpose of today's inspection was to go over the water lead test results received on 10/11/22. Results show that a water sources had action level exceedance of lead. The water fountain located on the hallway between the two classrooms had a lead result of 11. LPA observed the water bubbler was covered and disconnected. Per facility representative, facility provided sparkling water with paper cups for children to drink. A deficiency was cited to ensure that the water source noted would not be used as a drinking source or food preparation source for the children.

The deficiency listed on the following page were observed by the 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 needs to be cleared to protect the children’s health & safety. Plan of correction was cleared during today's visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Jacqueline Ruvalcaba.

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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 04/12/2024 10:30 AM - It Cannot Be Edited


Created By: Tiffanie Tran On 04/12/2024 at 10:05 AM
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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CARVER HEAD START/STATE PRESCHOOL
FACILITY NUMBER: 191597736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
101700.3(b)(1)-(b)

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Result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance This requirement was not met as evidence by record review. Lead test results showed that a water sources had an action level exceedance.
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Facility had provided correction record completed on 320/23 water outlet had been corrected. Facility provide filtered water for the children to drink.
POC cleared during today's visit.
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LPA observed the water bubbler had been covered and made inaccessible to children in care.This is a potential risk to the health and safety of the 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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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