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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605974
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:53:01 AM

Document Has Been Signed on 02/17/2023 10:53 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KING OF GLORY LUTHERAN CHURCHFACILITY NUMBER:
300605974
ADMINISTRATOR:DANIELS, STEPHANIEFACILITY TYPE:
850
ADDRESS:10280 SLATER AVETELEPHONE:
(714) 968-5865
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 74TOTAL ENROLLED CHILDREN: 74CENSUS: 47DATE:
02/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Assistant Director Loretta MunozTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Romy Castanon and LPA Archibaldo Silva conducted a case management visit. LPA’s met with Assistant Director Loretta Munoz to discuss the Lead Sampling Testing conducted on 12/21/2022. Director was advised on 02/07/2023 that the Lead Sample Report was to be posted. Director Stephanie Daniels provided LPA’s copies of all documentation requested regarding Lead; LIC 999 Facility Sketch, LIC 9275 and LIC 9276.

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 12/21/2022 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.

LPA’s observed outlet C had been permanently removed. Outlet C (6.85 ppb) was a fountain in Toddler Playground attached to the building. Facility provides water for children with gallon jugs and disposable cups. Children are also encouraged to bring their own water bottles.



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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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: KING OF GLORY LUTHERAN CHURCH
FACILITY NUMBER: 300605974
VISIT DATE: 02/17/2023
NARRATIVE
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Based on LPA's review of initial lead sampling documentation and interview with Assistant Director, the following violation is being cited in accordance with Written Directives Section 101700.3 (b)(1) California Lead Action Level at Child Care Centers, is being cited on the attached LIC 809D. LPA has confirmed the facility has permanently removed the outlet and will be providing a cleared plan of correction during visit on this date.

Exit interview was conducted and report was reviewed with Assistant Director Loretta Munoz. A notice of site visit was given and must remain posted for 30 days. Appeal Rights and deficiency were explained. The Director was provided a copy of appeal rights (LIC 9058) 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.

End of Report
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2023 10:53 AM - It Cannot Be Edited


Created By: Romelia M Castanon On 02/17/2023 at 10:31 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KING OF GLORY LUTHERAN CHURCH
FACILITY NUMBER: 300605974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited

101700.3(b)(1)

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101700.3 (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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All required lead documentation has been receieved by the department. During visit on 02/17/2023, LPA’s confirmed outlet C had been permanently removed.
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This requirement is not met as evidenced by record review of the lab report analysis from Outlet C taken on 12/21/2022. Results indicated levels of lead in exceedance (6.85 ppb). This poses a potential risk to the health and safety of children 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:Rina Lopez
LICENSING EVALUATOR NAME:Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
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