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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270967
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:35:41 AM

Document Has Been Signed on 04/11/2023 11:35 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KATHERINE IRVINE DAY SCHOOLFACILITY NUMBER:
304270967
ADMINISTRATOR:ROSA DOMINGUEZFACILITY TYPE:
850
ADDRESS:1002 WEST 2ND STREETTELEPHONE:
(714) 541-8164
CITY:SANTA ANASTATE: CAZIP CODE:
92701
CAPACITY: 64TOTAL ENROLLED CHILDREN: 64CENSUS: 30DATE:
04/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Director Rosa DominguezTIME COMPLETED:
11:00 AM
NARRATIVE
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809 Page 1
Licensing Program Analyst (LPA) Archibaldo Silva conducted a Case Management - Other visit to follow up on the Lead Test results dated 03/08/23. The test results and remediation plan for water outlet(s) B (located in classroom 2) were discussed with Director Rosa Dominguez. The results are at a Lead Action Level Exceedance with values of 5.860 ppb. The LPA reminded Director Dominguez that the instructions for required lead testing are outlined in PIN 21-21.1-CCP WRITTEN DIRECTIVES FOR LEAD TESTING OF WATER.

PIN 21-21.1-CCP WD has the same force and effects as the regulations contained in Title 22 of the California Code of Regulations. Per WD, Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers constructed before January 01, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and every 5 years after the date of the first test, and to notify parents or legal guardians of children enrolled of the requirement to test the drinking water and the results of the test.

Facility staff had previously provided copies of all documentation requested (LIC 999 Facility Sketch, LIC 9275, LIC 9276, and a copy of the remediation plan) to the Regional Office. LPA advised Site Supervisor Eva Hampton to post the Lead Sample Report (i.e. the test results) and confirmed that the Lead Sample Report was posted before leaving the facility. Facility staff began conditioning water outlet B in classroom 2 for follow-up sampling as instructed in section 101705 of the WD. The LPA spoke with Director of Education Program Valerie Padilla over the phone about the remediation plan and agreed to the removal of the plastic bag so that staff could more practically flush the water outlet four or more times per day. A sign reading DO NOT USE is posted in front of water outlet B. In addition, Director Rosa Dominguez stated that water faucet B is not used for drinking or food preparation and is rarely used. The teachers in classroom 2 are aware that water from outlet B is not suitable for human consumption.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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Document Has Been Signed on 04/11/2023 11:35 AM - It Cannot Be Edited


Created By: Archibaldo Silva On 04/11/2023 at 10:39 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: KATHERINE IRVINE DAY SCHOOL
FACILITY NUMBER: 304270967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited
CCR
101700.3

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(b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance; (b)(2) Licensees shall maintain a lead value at or below the Action Level in all outlets…
This requirement was not met as evidenced by:
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The licensee replaced the water faucet in outlet B classroom 2. The facility staff will follow instructions in Section 101705 of the WD to condition water outlet B for follow-up water sampling.
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Based on observation, interviews, and records review, the licensee did not comply with the above reulation in 1 out of 9 water outlets.
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Director Rosa Dominguez agrees to submit follow-up sampling results to LPA Silva by the due date 5/11/23.

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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:Patricia Magana
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KATHERINE IRVINE DAY SCHOOL
FACILITY NUMBER: 304270967
VISIT DATE: 04/11/2023
NARRATIVE
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809 Page 2
Census at the time of the visit was 30 preschool children: 14 in classroom 4 and 16 in classroom 2. A review of the Facility Personnel Report Summary indicated all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to the initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Based on LPA's observations, interviews with Director Rosa Dominguez (on-site), and Director of CCC and Education Program Valerie Padilla (off-site, over the phone), a review of the facility's sketch, and documentation regarding action taken to fix the identified outlet, the following violation was observed and is being cited in the attached 809D in accordance with WD PIN 21-21.1-CCP: Section 101700.3 California Lead Action Level at Child Care which states that (b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance and (b)(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to testing requirements….

An exit interview was conducted, and this 809 report was reviewed with Director Dominguez. A Notice of site visit was provided and must remain posted for 30 days. The Appeal Rights and deficiency were explained. The Director was provided a copy of the appeal rights (LIC 9058 01/16) and her 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 at the address listed above.



End of Report.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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