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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414967
Report Date: 11/22/2024
Date Signed: 11/22/2024 10:33:57 AM

Document Has Been Signed on 11/22/2024 10:33 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CAPISTRANO ELEMENTARY SCHOOL PRESCHOOLFACILITY NUMBER:
197414967
ADMINISTRATOR/
DIRECTOR:		GIBBS, ALICEFACILITY TYPE:
850
ADDRESS:8118 CAPISTRANO AVENUE ROOM #1TELEPHONE:
(818) 883-8981
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 24TOTAL ENROLLED CHILDREN: 16CENSUS: 15DATE:
11/22/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Sonja Cao-Garcia, PrincipalTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced case management inspection on 11/22/2024 for the purpose of addressing an Action Lead Exceedance (ALE) at the facility. LPA arrived to the facility at 8:45AM and met with Sonja Cao-Garcia, Principal, who guided analyst on a tour of the facility. LPA observed 15 children with 2 staff upon arrival.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires all licensed Child Care Centers (CCC’s) constructed before January 1,2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every five years after the date of the first test.

Community Care Licensing was notified of the results of the Lead Water Testing conducted at the facility on 10/21/2022. The sample testing was for Outlet "A" with results above 5.5 ppb which is considered an exceedance. Outlet "A" was reported to have an exceedance of 374ppb. LPA was not able to verify which outlets were tested because a facility sketch was not provided to the Department prior or during the inspection. On 04/05/2024, The Department received information for the facility's plant manager stating Classroom 1's water filter had been installed. Per Principal, documents were not available at the facility for LPA to obtain copies.

Documents pending are as followed:
  1. Completed External Water Sampler Self-Certification Form (LIC 9275)
  2. Completed Child Care Center Sampling Checklist Form (LIC 9276)
  3. Facility Sketch identifying the location of water outlet/s used for drinking
  4. A copy of the initial water testing results for outlets tested
  5. Proof of corrections for Outlet "A"
  6. A copy of water retesting results summary for Outlets "A"
  7. A plan on how often Outlet "A" filter will be serviced.
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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAPISTRANO ELEMENTARY SCHOOL PRESCHOOL
FACILITY NUMBER: 197414967
VISIT DATE: 11/22/2024
NARRATIVE
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Principal was advised to posted lead testing results, in a location consistent with the requirements of subsection (b) of section 1596.8595 of the Health & Safety Code, for parents and families to view at the facility within 24-hours of receiving the results from the Department. Facility will notify all parents or guardians of children in care of lead exceedance results and what has been done to date and remediation plan for water outlet “A”.

Based on interviews and results reported to the Department, it has been determined that CAPISTRANO ELEMENTARY SCHOOL PRESCHOOL violated Child Care Licensing Regulation Division 12, Chapter 1, Subchapter 5 101700.3 (b)(1) California Lead Action Level at Child Care Centers.

A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care. Refer to LIC 809-D for deficiency page.

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

Exit interview conducted and report was reviewed with Sonja Cao-Garcia, Principal.

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SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2024 10:33 AM - It Cannot Be Edited


Created By: Lilia Hernandez On 11/22/2024 at 09:57 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: CAPISTRANO ELEMENTARY SCHOOL PRESCHOOL
FACILITY NUMBER: 197414967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
100700.3(b)(1)

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(b) Testing results with fractional ppb readings of 0.5 ppb or greater...(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidence by:
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Per Principal, the following documents will be submitted to LPA via email by POC due date: Completed External Water Sampler Self-Certification Form (LIC 9275), Completed Child Care Center Sampling Checklist Form (LIC 9276),Facility Sketch identifying the location of water outlet/s used for drinking,
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Based on results submitted to the Department, the facility did not comply with the section cited above in Outlet "A" was reported to have an exceedance of 374 ppb, exceeding allowable limit for lead, which poses a potential Health, Safety or Personal Rights risk to persons in care.
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a copy of the initial water testing results for outlets tested, Proof of corrections for Outlet "A" a copy of water retesting results summary for Outlets "A", and A plan on how often Outlet "A" filter will be serviced.

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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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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