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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417494
Report Date: 05/09/2023
Date Signed: 05/10/2023 08:08:13 AM

Document Has Been Signed on 05/10/2023 08:08 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JEFFERSON STATE PRESCHOOLFACILITY NUMBER:
197417494
ADMINISTRATOR:RIOS-PARRA NELLIEFACILITY TYPE:
850
ADDRESS:10203 FIRMONA AVENUETELEPHONE:
(310) 680-3500
CITY:LENNOXSTATE: CAZIP CODE:
90304
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 54DATE:
05/09/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nellie Parra-Rios, Site DirectorTIME COMPLETED:
01:55 PM
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On 5/9/2023, Licensing Program Analyst (LPA) Judy Laureano conducted an unannounced case management visit. LPA Laureano was greeted by Nellie Parra Rios. Director guided LPA Laureano on a tour of the facility. There were 54 children and 9 staff members providing care and supervision, including site director N Parras- Rios.

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 that lead water testing conducted at the facility on 3/25/2023 exceeded allowable limit for lead. Samples testing over 5.5 ppb/ug L and above is considered an exceedance. The Purpose of today’s visit is to follow up lead testing results of Action Level Exceedances (ALE) and conduct an inspection.

On 3/31/2023 LPA Laureano via email received the following documents from facility, LIC 9275, LIC 9276, Facility Sketch (water faucets/outlets identified). LPA Laureano took pictures of water outlet/bubbler in classroom 24.

The facility has been identified to have 1 water facet/outlet with an Action Level Exceedance (ALE) in the amount of lead in water being 5.5pb, or greater. LPA Laureano confirmed with director the following outlet/faucets, “D” in classroom 24, identified as exceedance of lead and shall remain inoperable. Classroom 24 has not been in use and children do not have access to the area.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JEFFERSON STATE PRESCHOOL
FACILITY NUMBER: 197417494
VISIT DATE: 05/09/2023
NARRATIVE
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LPA Laureano observed all outlets identified with an Action Level Exceedance to be made inaccessible to the children in care. LPA Interviewed director and staff to ensure children do not have access to the identified outlet/water bubbler that has been identified as exceedance of lead. Children have access to water via water bottles in each classroom and children bring in their own refillable water bottles. LPA observed a water bottles in the facility as well as children’s refillable water bottles.

Based on observation, interviews and sampling records it has been determined that there was a violation of Licensing Regulation Title Division 12, Chapter 1, Subchapter 5 – California Lead Action Level at Child Care Centers 101700.3(b)(1), “A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance”. Lead water testing samples taken on 3/25/2023 revealed that levels of lead were beyond allowable amount deemed by the State of California. This facility is being cited (1) deficiency during today’s visit 5/9/2023. This is a type B violation which poses a potential Health, Safety or Personal Rights risk to persons in care. In Accordance with California Code of Regulations. Refer to LIC 809-D.

LPA discussed Proof of Correction (POC) with Director. All faucets identified with an Action Lead Exceedance of 5.5 ppb or over have been made inaccessible to the children in care. The outlet will not be accessible for use until a retest has occurred. A notification of letter will be drafted by facility to sent out to parents with notification of cease of water outlets and remediation for planned for water outlets or alternative. Director will send LPA a copy of the letter via email by 5/28/2023. Facility will work to begin repairs and will notified LPA when repairs are schedule. Facility will work on scheduling for a second test of identified outlets when repairs are completed. Director will LPA a copy of the re-test summary once completed.

Instructions for required lead testing are outlined in PIN 21-21. This PIN which contains Written Directives, have the same force and effects as the regulations contained in Title 22 of the California Code of Regulations Care Child Centers are expected to use an Environmental Laboratory Accreditation Program (ELAP), for lead testing. Accreditation from the California Environmental Laboratory Accreditation Program, known as an ELAP laboratory, is equipped to measure the amount of lead in a parts per billion (ppb) unit of measurement.

For more information, go to the California Childhood. Lead Poisoning Prevention Branch’s website at www.cdph.ca.gov/programs/clppb or call them at (510) 620-5600. Please see Provider Information Notice (PIN) 20-01-CCP for more information about lead toxicity prevention

Director received Notice of Site Visit and copy of this report.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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Document Has Been Signed on 05/10/2023 08:08 AM - It Cannot Be Edited


Created By: Judy Laureano On 05/09/2023 at 03:01 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JEFFERSON STATE PRESCHOOL
FACILITY NUMBER: 197417494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2023
Section Cited
CCR
101700.3(b)(1)

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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
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Water outle/ bubbler has been placed inoperable. Facility sumbitted a plan of correction to LPA Water outlet in room 24 is not available to children. Classroom is closed.
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Based on observation and review of Lead water testing samples taken on 3/23, revealed that levels of lead were beyond allowable amount deemed by the State of California. Room 23 water outlet had a lead exceedance levels of sample "D" at 7.3. This poses a potential health and safety risk to children in care.
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Facility will make repairs, notified famiiles of the lead testing and will provide LPA with a copy of the notificaiton by 5/28/23. A restest will been completed and once results are availalbe, a copy will be sent out to LPA.

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


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