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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198002131
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:21:28 PM

Document Has Been Signed on 11/13/2023 02:21 PM - 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:HAWAIIAN HEAD START/ STATE PRESCHOOLFACILITY NUMBER:
198002131
ADMINISTRATOR:CONSUELO GUZMANFACILITY TYPE:
850
ADDRESS:12350 E. 226TH ST.TELEPHONE:
(562) 229-7921
CITY:HAWAIIAN GARDENSSTATE: CAZIP CODE:
90716
CAPACITY: 24TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
11/13/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:00 AM
MET WITH:Veronica MartinezTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. Tran conducted an unannounced case management for Lead at Hawaiian Gardens. Upon arrival, LPA met with Veronica Martinez, Head Teacher, and we toured the facility.

The purpose of today's inspection was to go over the water lead test results received on 03/07/23. Results show that a water source had action level exceedance of lead. The water fountain located at the outdoor play area had a lead result of over 7.800 LPA observed water fountain was covered with bag and tape to make them inaccessible to children. LPA spoke with facility representative who stated facility have filtered water delivered to the site for children to use. A deficiency was cited to ensure that the water fountain noted will 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 LPA 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 is 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, Veronica Martinez.

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/13/2023 02:21 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 11/13/2023 at 01:59 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: HAWAIIAN HEAD START/ STATE PRESCHOOL
FACILITY NUMBER: 198002131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2023
Section Cited
CCR
101700.3(b)(1)

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This requirement was not met as evidence by record review. Lead test results showed that a water source had an action level exceedance. LPA observed the water fountain to be made inaccessible with plastic bags and tape.
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On 03/30/23, facility had provided a written statement on their plan to continue to ensure that the water sources will not be used as a drinking or food preparation source. Photo images of water faucets was covered by black bags with tape labeled as out of order, do not use.
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The water fountain located outside was also turned off. This is a potential risk to the health and safety of the children in care.
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Facility provide filtered water for the children to drink daily.
POC was cleared during today's visit.

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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: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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