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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300603950
Report Date: 03/10/2023
Date Signed: 03/10/2023 01:42:02 PM

Document Has Been Signed on 03/10/2023 01:42 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:HARBOR TRINITY PRESCHOOLFACILITY NUMBER:
300603950
ADMINISTRATOR:DAVIDSON, JENNIFERFACILITY TYPE:
850
ADDRESS:1230 BAKER STTELEPHONE:
(714) 556-4335
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 42DATE:
03/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Diane Dudley Assistant Director TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced Case Management visit for the purpose to discuss the Lead Sampling Testing conducted 1/24/23. LPA met with Assistant Director Diane Dudley who was explained the reason for today’s visit. LPA observed 42 children in care at the time of 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 1/24/23 failed allowable limit for lead. The Purpose of today’s visit is to follow up lead testing results of Action Level Exceedance (ALE).

Instructions for required lead testing are outlined in PIN 21-21-CCP. 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.

Child Care 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 parts per billion (ppb) unit of measurement.


Facility staff was advised on 3/7/2023 that the Lead Sample Report was to be posted. LPA observed the facility had posted the Lead Sample Report.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: HARBOR TRINITY PRESCHOOL
FACILITY NUMBER: 300603950
VISIT DATE: 03/10/2023
NARRATIVE
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Site ID A is the only site that tested positive. The faucet is located outside of classrooms by the children’s restrooms. Site ID A is a drinking faucet that had a level of 20.000 parts per billion (ppb). Currently the site has a trash bag taped over and covering outlet, and a sign that reads "Out of Order." Children in care bring their own individual water bottles from home. Facility also provides drinking water for children in care in the means of drinking faucets and refillable water stations which have passed lead testing.

Based on LPAs interview with staff, review of facility sketch and walk-through, the following violation was observed and is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 3, Section 101700.3 California Lead Action Level at Child Care Centers is being cited on the attached LIC 809D.



Exit interview conducted with Assistant Director, Diane Dudley. The report was reviewed and discussed. Appeal Rights were discussed. Director was provided copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received the Regional Office within 15 business days.

Director was informed that the "Notice of Site Visit" must be posted for 30 consecutive days. The Notice of Site Visit must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2023 01:42 PM - It Cannot Be Edited


Created By: Patricia Duron On 03/10/2023 at 12:26 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: HARBOR TRINITY PRESCHOOL
FACILITY NUMBER: 300603950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (b) Testing results with fractional ppb readings of 5.0 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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LPA observed Site ID A located outside classroom by children’s restrooms with a sign that reads "Out of Order" Children in care bring their own individual water bottles from home. Facility also provides drinking water for children in care in the means of drinking faucets and refillable water stations which have passed lead testing.Facility will re-test on March 21, 2023 and submit results to LPA Duron.
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Based on lab report analysis water from outlet A (20.000 parts per billion) taken on 1/24/2023 indicated levels of lead in exceedance. Staff stated facility is scheduled to re-test outlet on March 21, 2023.
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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:Thuy Ho
LICENSING EVALUATOR NAME:Patricia Duron
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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