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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364807114
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:32:00 PM

Document Has Been Signed on 11/08/2024 01:32 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SBCUSD-CYPRESS ELEMENTARYFACILITY NUMBER:
364807114
ADMINISTRATOR/
DIRECTOR:		KELLY, LATASHIAFACILITY TYPE:
850
ADDRESS:26825 CYPRESSTELEPHONE:
(909) 388-6514
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 8DATE:
11/08/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Mary Carmen LandaTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Due to required lead testing requirements, Licensing Program Analyst (LPA), Justin Giese conducted a Case Management inspection based on lead testing results received from the facility. LPA toured the facility, took census and met with Permit Teacher, Mary Carmen Landa to further discuss lead testing results received and measures taken for remediation of lead exceedances.

The Facility conducted initial water/lead testing on drinking fountain outlets on 01/19/2023. Outlet C, which was identified as a drinking fountain bubbler located on the exterior of the facility building, tested with a result of 7.4ppb. LPA was informed by the Permit Teacher, the outlet was placed out of service and signs posted for cessation of use.

The facility employed remediation efforts and conducted a subsequent test on Outlet C on 10/03/2023, which yielded a satisfactory result of 1.8ppb. LPA observed outlet C to be functioning and in service during todays inspection.

Although facility took immediate action to remedy outlet C's exceedance, due to water outlet C's initial testing on 1/19/2023 with a lead exceedance above approved lead levels, a deficiency has been cited. See LIC809D for Type B Deficiency.

This deficiency will be cited and cleared as part of todays inspection.

An exit interview was conducted, and appeal rights were provided/discussed. LPA provided Permit Teacher, Mary Carmen Landa with a copy of this report and notice of site visit, which must be posted for the next 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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 11/08/2024 01:32 PM - It Cannot Be Edited


Created By: Justin Giese On 11/08/2024 at 01:03 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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SBCUSD-CYPRESS ELEMENTARY
FACILITY NUMBER: 364807114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
101700.3(b)(1)

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California Lead Action Level at Child Care Centers 101700.3 (b)(1): A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.


This is evidenced by:
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Although facility took action to remedy outlet C's exceedance, due to water outlet C's initial testing on 1/19/2023 with a lead exceedance above approved lead levels, a deficiency has been cited. The facility employed remediation efforts and conducted a subsequent test on Outlet C on 10/03/2023 which yielded
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Based on records review of required lead testing, the facility had lead values of 5.5 or above on water outlet C (7.4ppb)

This is a potential health and safety risk to persons in care.
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a satisfactory result of 1.8ppb. LPA observed outlet C to be functioning and in service during todays inspection.

This deficiency will be cited and cleared as part of todays inspection.

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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