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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197750142
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:37:42 AM

Document Has Been Signed on 10/05/2022 10:37 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:WOODEN SHOE PRESCHOOLFACILITY NUMBER:
197750142
ADMINISTRATOR:MARTHA T VELOZFACILITY TYPE:
850
ADDRESS:1525 GLENOAKS BLVDTELEPHONE:
(818) 365-1513
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 74TOTAL ENROLLED CHILDREN: 74CENSUS: 23DATE:
10/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Martha Veloz, DirectorTIME COMPLETED:
10:45 AM
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On 10/05/22, Licensing Program Analysts (LPAs) Justeene Tamayo and Barbara Beneroso conducted a Case Management inspection in response to information received from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The water samples collected were reported on the prior facility number 191202198. Due to new ownership of this facility, this case management will be reported on new license number 197750142. This incident occurred while the facility was on different ownership. LPAs Tamayo and Beneroso met with the Director Martha Veloz, the purpose of the inspection was disclosed, and entry was granted. Upon arrival LPAs observed 23 children were observed and 4 staff present today.

During the inspection, LPAs Tamayo and Beneroso informed Director, the results provided from SWRCB, indicated the facility had elevated levels of lead in the water in the indoor drinking fountains (Samples C (classroom 22A), E (classroom 23A), and F (classroom 23B). The Department was notified of the Action Level Exceedance (ALE), levels are at Drinking fountain C presented levels of 18.00 UG/L , drinking water fountain E presented levels of 10.00 UG/L, and drinking water fountain F presented levels of 11.00 UG/L. The SWRCB report sample listed facility inspected and collected sample on 08/26/22 . Results were provided to facility on 09/04/2022. Lab Job Number: 01051

Director notified LPA Tamayo within the required timeline.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WOODEN SHOE PRESCHOOL
FACILITY NUMBER: 197750142
VISIT DATE: 10/05/2022
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LPAs advised Director, all water outlets tested with an ALE at the facility should be placed as out of service and children should be provided with an alternative potable water. LPAs observed water bottles in every classroom for a substitute of drinking water.

Director advised LPAs Tamayo and Beneroso per the sample results, the drinking fountains from sample water C, E, F had high levels of lead. LPAs Tamayo and Beneroso observed the drinking water fountains to be covered and taped for inaccessibility to children present. Director has notified all parents and will post a sign at each water fountain affected. According to Director, last day drinking fountains were utilized by children was during the summer from June 2022 to beginning of September 2022 once the results were obtained. The Director stated the drinking fountains C,E,F will be assessed for repair. Per Director, the facility is currently waiting on the estimate of each faucet repair.

Once the repairs are made, director will retest water for lead and notify LPAs of results after 3 weeks. Director is aware the lead levels shall not exceed 5.00 UG/L

Per director, the entire fixture will be replaced and re-tested.

An exit interview was conducted and a copy of this report was provided. along with a Notice of Site Visit and appeal rights to Director Martha Veloz.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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