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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334818811
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:54:50 PM

Document Has Been Signed on 04/24/2023 04:54 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:CALVARY CHAPEL ACADEMY PRESCHOOLFACILITY NUMBER:
334818811
ADMINISTRATOR:MICHELLE CORTESFACILITY TYPE:
850
ADDRESS:26121 HEMET STREETTELEPHONE:
(951) 927-4395
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 54TOTAL ENROLLED CHILDREN: 54CENSUS: 8DATE:
04/24/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
04:12 PM
MET WITH:Michelle Cortes TIME COMPLETED:
05:13 PM
NARRATIVE
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On April 24, 2023, at 4:12 PM, Licensing Program Analyst’s (LPA’s) Anastasia Flores, made an unannounced Case Management inspection, for reported Lead Exceedance. LPA met with Director, Michelle Cortes and proceeded to tour the facility. Also present in the facility were 8 preschool children, 3 teachers/staff. Facility was within ratio & capacity. On 04/24/23, LPA Anastasia Flores interviewed the director, and examined the faucets and drinking fountains deemed an Action Level Exceedance. Facility provided facility sketch and plan of correction via email on 04/20/23. The required signed and dated forms (LIC 9275/9276) were submitted to Community Care Licensing via email on 04/20/23.

Label C, D & F: faucets & drinking fountain reported with 5.00 ppb or greater lead exceedance levels were as follows:

Label C faucet in room #2, identified as having high levels of lead read at 5.5 ppb. Label D in room #3, faucet as having high levels of lead read at 19 ppb. Label F, drinking fountain in corridor 1, as having high levels of lead at 12 ppb. The faucets in the classrooms have been turned off and are no longer being used by the children and staff to wash hands. The children are utilizing the bathrooms to wash hands and bottled water is provided for the children in care. The drinking fountain in corridor 1 has been covered with plastic to avoid contact by children in care or staff. On 04/24/23, LPA Flores, was informed that the fountain has not been used by anyone. LPA was informed the faucets in all classrooms will have a filter placed and retested.

Based on records review and information received, and current policies and procedures for the Department, the facility is being cited for having a lead exceedance in water fountain labeled letter C, D, F, under the Written Directives, Section 101700.3 (b) (1) California Lead Action Level at Child Care Centers. This poses a potential health, safety, or personal rights risk to the children in care.

An exit interview was conducted, a copy of this report, 809D and appeal rights were handed to facility Director, Michelle Cortes. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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 04/24/2023 04:54 PM - It Cannot Be Edited


Created By: Anastasia Flores On 04/24/2023 at 04:40 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CALVARY CHAPEL ACADEMY PRESCHOOL
FACILITY NUMBER: 334818811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
101700.3(b)(1)

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Section 101700.3 (b) (1) California Lead Action Level at Child Care Centers 101700.3 (b) (1) Written Directives...A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidence by:
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The drinking faucets in the classrooms have been turned off and are no longer being used by the children and staff to wash hands. The children are utilizing the bathrooms to wash hands and bottled water is provided for the children in care. The drinking fountain in corridor 1 has been covered with plastic to avoid contact by children in care or staff.
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Based on records review and interviews, facility tested over the Action Level Exceedance, in two faucets labeled C & D and one drinking fountain labeled F in corridor 1. This poses a potential health, safety, or personal rights risk to the 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:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023


LIC809 (FAS) - (06/04)
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