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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270029
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:08:43 AM

Document Has Been Signed on 12/08/2022 11:08 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:CAPO BEACH CHURCH PRESCHOOLFACILITY NUMBER:
304270029
ADMINISTRATOR:STEPHAN, JOSIEFACILITY TYPE:
850
ADDRESS:25975 DOMINGO AVE. RMS.7,8,9TELEPHONE:
(949) 443-1316
CITY:CAPISTRANO BEACHSTATE: CAZIP CODE:
92624
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 14DATE:
12/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maggie Penuelas - DirectorTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPAs) Odom and Lucero conducted an unannounced Case Management visit. LPA Odom met with Director Maggie Penuelas, took a tour of the facility and took census, LPAs observed 2 staff members and 15 preschool age children. LPA discussed the Lead Sampling Testing conducted on 11/15/22 with Director. LPA Odom ensured the Lead Sample Report is posted. Licensee was advised on 12/08/22 the Lead Sample Report was to be posted; LPA confirmed the Licensee posted the Sample Report.

Director stated the outlets with high levels of Lead are inoperable. Outlet F is a drinking fountain in Rm #9 that will be remediated, the drinking fountain has been replaced and will be retested on 12/13/22. Outlet G is an outdoor drinking fountain in the Playground that will be remediated, faucet has been removed, it will be replaced and retested on 12/13/22. Outlet H is a hand washing sink in the Playground that will be remediated, faucet has been removed, faucet will be been replaced and retested on 12/13/22. Director has placed signs to advise staff and children that the outlets are closed off. Source of drinking water is children’s water bottles brought from home and refilled by staff using filtered water dispensers.

Based on LPAs record reviews 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 and report was reviewed with the Director Maggie Penuelas. 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: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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 12/08/2022 11:08 AM - It Cannot Be Edited


Created By: Carmen Odom On 12/08/2022 at 10:54 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: CAPO BEACH CHURCH PRESCHOOL
FACILITY NUMBER: 304270029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2022
Section Cited

101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers (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. This requirement was not met as evidenced by:
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Director posted the lead sampling test results. Director placed signs on the outlets to make sure that staff and children do not use the faucets. Director is utilizing filtered water dispensers as another source of water and using personal water bottles as source of drinking water.
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Based on facility Lead sampling tests it was discovered that Outlets F, G, and H had high level of lead. This poses a potential risk to the health of children in care.
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Director stated they will replace the faucets and are scheduled to retest on 12/13/22. Director will submit retest results by 12/31/22.

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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:Judy Hanson
LICENSING EVALUATOR NAME:Carmen Odom
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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