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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494574
Report Date: 12/13/2022
Date Signed: 12/13/2022 10:49:04 AM

Document Has Been Signed on 12/13/2022 10:49 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:DEVONSHIRE PRESCHOOLFACILITY NUMBER:
197494574
ADMINISTRATOR:JACQUELINE SORIA LOPEZFACILITY TYPE:
850
ADDRESS:21203 DEVONSHIRE STREETTELEPHONE:
(818) 700-2821
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 60TOTAL ENROLLED CHILDREN: 38CENSUS: 21DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cynthia Morales, Assistant DirectorTIME COMPLETED:
11:20 AM
NARRATIVE
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On 12/13/2022 Licensing Program Analyst (LPA) Suzette Ornelas conducted an unannounced case management visit. LPA was greeted by Cynthia Morales, Assistant Director who granted entry into the facility and guided LPA on a tour. LPA observed 4 teachers and 21 children present during the visit.

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 11/03/2022 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 on the lead testing results of Action Level Exceedances (ALE) and conduct an inspection.

Director, JACQUELINE SORIA LOPEZ provided LPA with a copy of the following documents via email on 12/12/2022: External Water Sample Self-Certification Form (LIC 9275), Signed and dated Child Care Center Sampling Checklist Form (LIC 9276), Facility Sketch (fully labeled with locations of all water outlets). LPA will upload the documents to the CA State Water Resources Control Board, Division of Drinking Water Database (DDW) database.

Testing was conducted on 11/03/2022. Per the report, the following water outlets yielded the following results:

1.) Faucet/Outlet B- Sink in Room 3 - 71 ppb/ug

2.) Faucet/Outlet C- Sink in the Kitchen - 6.1 ppb/ug

During today’s visit LPA observed water facet/outlets identified on facility sketch. LPA confirmed with assistant director that faucet/outlet B in Room 3 and faucet/outlet C in the Kitchen, samples were identified with exceedance of lead and shall remain inoperable.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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: DEVONSHIRE PRESCHOOL
FACILITY NUMBER: 197494574
VISIT DATE: 12/13/2022
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LPA observed faucet/outlet locations. The faucet/outlets were observed to be inoperable, covered, shut off and labeled off. The children and staff do not have access to outlet/faucets. Per assistant director, sink located in the kitchen has a faucet/outlet along with a filtered drinking water faucet/outlet. The faucet/outlet in Room 3 (B) is used for washing hands only. Per assistant director, facility ceased the use of faucet/outlets. LPA observed 5, 1 gallon and 3, 3 liter water bottles of potable drinking water located next to the kitchen sink. Per assistant director, water will be replenished as needed. Plumbing company has been contacted and facility is taking all appropriate steps to meet requirements. Per assistant director children bring their own water bottles and water bottles are re-filled with bottled water.

LPA provided facility representative with Instructions for required lead testing outlined in PIN 21-21 CCP and Lead Testing Question and Answers. This PIN contains Written Directives, which have the same force and effects as the regulations contained in Title 22 of the California Code of Regulations.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

LPA provided technical assistance and discussed wavier for drinking water as outlined in PIN 21-21-CCP.

Based on observation, interviews and supportive documents it has been determined that the facility 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. Lead water testing samples taken on 11/03/2022 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. 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.

LPA discussed Proof of Correction (POC) with Assistant Director demonstrated that all required actions were taken to correct the violation once discovered. As mentioned earlier director submitted all required licensing forms, supportive documents and plan of correction.

A notice of site visit (LIC 9213) was given and must remain posted for 30 days.

An Exit interview was conducted, report was reviewed with the Assistant Director Cynthia Morales. Licensee was provided a copy of the report and appeal rights.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2022 10:49 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 12/13/2022 at 10:24 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: DEVONSHIRE PRESCHOOL
FACILITY NUMBER: 197494574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2022
Section Cited
CCR
101700.3(b)(1)

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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 requirement is not met as evidenced by: Lead water testing samples taken on 11/03/2022 revealed that levels of lead
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Per Assistant Director, facility will either replace fixtures or submit a plan on how to provide potable water to children in care. Director will provide plan of correction and any update as necessary by 12/30/2022.
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were beyond the allowable amount deemed by the State of California. This is a type B violation which poses 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:Lisa Rios
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


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