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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900458
Report Date: 01/11/2023
Date Signed: 01/11/2023 12:43:14 PM

Document Has Been Signed on 01/11/2023 12:43 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HESPERIA COMMUNITY CHURCH PRESCHOOLFACILITY NUMBER:
360900458
ADMINISTRATOR:JACQUELYN MANSFIELDFACILITY TYPE:
850
ADDRESS:16775 OLIVE STREETTELEPHONE:
(760) 244-6164
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 67TOTAL ENROLLED CHILDREN: 67CENSUS: 51DATE:
01/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jackie Mansfield, Preschool DirectorTIME COMPLETED:
12:45 PM
NARRATIVE
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On January 11 2023, at 10:15 a.m., Licensing Program Analysts (LPA) Kuliema Calloway, conducted a Case Management inspection in response to information received from the California Rural Water Association (CRWA). LPA met with Jackie Mansfield, Preschool Director to discuss the purpose of the inspection and entry was granted. LPA observed fifty-one (51) children and ten (10) staff in care.

The CRWA report listed the facility was inspected and water samples were collected on 05/17/2022 for lab testing. The results of the lead sample testing (work order number 22-18050) were received in Pace Analytical Environmental Sciences laboratory on 8/2/2022. A work order was prepared on 10/21/22 by the Preschool Director with a request to remove the outside drinking fountain(s) by November 2, 2022. On 10/31/2022, CCLD was notified via email of the lab results indicating the Action Level Exceedance (ALE) were at 22 ppb for outside drinking fountain identified as 360900458 C and 19 ppb for outside drinking fountain flushed 360900458 C30, this fountain is located on the Pre-school playground near classrooms 31 and 32. LPA observed water fountain was completely removed.

During the inspection, LPA advised Director, the water outlets that tested with an ALE level at the facility should be inoperable and children should be provided with an alternative water source. Per the Director, children are not drinking from the outlet, moreover use of the identified outlets for drinking has immediately ceased and removed from service as of 7/29/22 when the facility was informed that the outlets were found to have lead levels above the 5 ppb Action Level. Notification to the parents was not provided and testing results were not posted on the parent’s board at the facility. Per the Director, alternative drinking water sources are provided from a portable five gallon Igloo cooler. The water is changed daily, and the children are using disposable drinking cups or their own water bottles.

Continued on 809 C

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: HESPERIA COMMUNITY CHURCH PRESCHOOL
FACILITY NUMBER: 360900458
VISIT DATE: 01/11/2023
NARRATIVE
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On 1/9/2023, the Director submitted a written Plan of Correction statement to the Palmdale Regional Office via email, indicating the alternative water source for the outlet Drinking Fountain Outside C 22 ppb and Drinking Fountain Outside- Flushed C30 19 ppb). The plan to replace the fountain will be scheduled near the Summer of 2023.

At the visit,LPA received an updated work order indicating that the fountain was removed on 10/26/2022.

There were two Type- B deficiencies 101703(a) and 101703(b) cited at the time of the visit. In accordance with the Written Directives for not submitting post testing requirements and usage of the water fountain prior to COVID-19 and failure to notify the parents once the water sampling testing results were completed.

An exit interview was conducted, and appeal rights were discussed. A copy of Notice of Site Visit, appeal rights, 809D, and a copy of this report were provided to site Preschool Director, Jackie Mansfield.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
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Document Has Been Signed on 01/11/2023 12:43 PM - It Cannot Be Edited


Created By: Kuliema Calloway On 01/11/2023 at 11:30 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: HESPERIA COMMUNITY CHURCH PRESCHOOL
FACILITY NUMBER: 360900458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2023
Section Cited

101703(a)

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101703 (a) A fully completed and signed copy of documents shall be sent to CCLD within two weeks of completed sampling date. This requrement was not met as evidenced by:
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Licensee will submit LIC 999 facility sketch, LIC 9275, and LIC 9276 documents per post water sample testing requirements to CCLD no later than 1/31/2023.
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Based on record review and interviews with the Preschool Director the Post-Testing required documents and information were not submitted.
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Type B
01/11/2023
Section Cited
101703(b)

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101703 (b) Upon receiving testing results from ELAP lab licensee shall post testing results in a location consistent with 1596.8595 of HSC for parents and families to view at facilty within 24 hrs of receiving the results. This requirement was not met as evidenced by:
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Licensee will provide a written POC to LPA by 1/11/2023 regarding parenting notification procedures.
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Based on record review and interviews with the Preschool Director the parents were not notified of the lead water sample results and the fountain was utilized prior to COVID-19.
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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:Claretta Yates
LICENSING EVALUATOR NAME:Kuliema Calloway
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


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