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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600825
Report Date: 09/19/2022
Date Signed: 09/19/2022 01:03:05 PM

Document Has Been Signed on 09/19/2022 01:03 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:RED HILL EVANGELICAL LUTHERAN CHURCHFACILITY NUMBER:
300600825
ADMINISTRATOR:CAAMANO, ANNA MARIAFACILITY TYPE:
850
ADDRESS:13200 RED HILL AVENUETELEPHONE:
(714) 544-3132
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 103TOTAL ENROLLED CHILDREN: 103CENSUS: 79DATE:
09/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ana Maria CaamanoTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Romy Castanon conducted an unannounced Case Management visit. LPA met with Director, Ana Maria (Annie) Caamano to discuss the Lead Sampling Testing conducted on 8/09/22. Director was advised on 09/16/22 that the Lead Sample Report was to be posted. Director emailed LPA all documentation requested regarding Lead. LPA confirmed that Director had posted the Lead Sample Report during visit.

LPA observed outlet C was located in Room 9 with a "NOT IN SERVICE" sign posted. Director informed LPA that outlet C is not being used for food preparation or drinking. Director informed LPA that the faucet has been replaced on 09/18/2022 and facility would like for it to be retested. Director stated that CA Rural Water Association could not return unless it was directed by the state. Director will include LPA in correspondence regarding lead retesting for outlet C. LPA informed Director that outlet needed to be covered and inoperable for the time being. During visit, LPA observed Director cover outlet via black trash bag and duct tape. Facility provides filtered water in dispensers and paper cups. Children are also allowed to bring their own water bottles.

Based on LPA's record reviews the following violation was observed and is being cited in accordance with
California Code of Regulations Title 22, Division 12, Chapter 1, Subchaper 5 Section 101700.3(b)(1) California Lead Action Level at Child Cares on the attached LIC 809D.

Exit interview conducted and report was reviewed with the facility representative Ana Maria Caamano. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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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Document Has Been Signed on 09/19/2022 01:03 PM - It Cannot Be Edited


Created By: Romelia M Castanon On 09/19/2022 at 12:40 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RED HILL EVANGELICAL LUTHERAN CHURCH
FACILITY NUMBER: 300600825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited

101700.3(b)(1)

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(b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level.
(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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 Director informed LPA that the faucet has been replaced on 09/18.Outlet C is inoperable via black trash bag and duct tape. Facility plans to have outlet flushed and retested. Director will send new test results to licensing office.

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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:Rina Lopez
LICENSING EVALUATOR NAME:Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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