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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364812085
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:47:07 AM

Document Has Been Signed on 01/13/2023 11:47 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SJUSD-PINON HILLS ELEMENTARY SCH. STATE PRESCHOOLFACILITY NUMBER:
364812085
ADMINISTRATOR:KIMBERLY MARTINFACILITY TYPE:
850
ADDRESS:878 MONO ROADTELEPHONE:
(760) 792-8097
CITY:PINON HILLSSTATE: CAZIP CODE:
92372
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 19DATE:
01/13/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Gabriela MartinezTIME COMPLETED:
12:00 PM
NARRATIVE
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On 01/ 13 / 2023 Licensing Program Analyst (LPA) Babatunde Ibitoye conducted an unannounced case management inspection. LPA met with Lead Teacher Gabriela Martinez. The purpose of today's inspection is to conduct a case management inspection, and to notify them there has been a lead exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at the facility.

Palmdale Regional Office received notification of water lead exceedance at the facility resulting from a recent water lead sampling test. Based on the records reviewed outlet (E) in the classroom Bottle Fillup Station drinking fountain has an ALE of 6..44 ppb.

Lead Teacher has disconnected the water outlet (E) until repairs can be made. Bottle water is available to preschool children during daycare hours- ^see plan of correction for further corrective action 809D). The center has notified authorized representatives of this corrective action in both languages English and Spanish

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, A type B deficiency is being cited (see LIC 809 D). Lead Teacher was provided a copy of the appeal rights. An exit interview was conducted with Lead Teacher Gabriel Martiez

This report shall be made available to the public upon request. The Notice of Site Visit is provided an required to be posted for 30 days

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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 01/13/2023 11:47 AM - It Cannot Be Edited


Created By: Babatunde Ibitoye On 01/13/2023 at 11:24 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: SJUSD-PINON HILLS ELEMENTARY SCH. STATE PRESCHOOL
FACILITY NUMBER: 364812085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2023
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (a) California’s Action Level for lead in water at Child Care Centers is 5 ppb. (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. (c) If testing indicates an Action Level Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response pursuant to section 101704 shall be required
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1.The ooutlet (E) in the classroom Bottle fillup drinking fountain has disconnected and Inacceaseable to children in care until repairs can be made by due date.
2.Bottle water is available to preschool children during daycare hours-
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This requirement was not met evidence by base on the information received from outlet, (E) in the classroom Bottle fillup drinking fountain has an ALE of 6.44 ppb and from outlet,which is out of compliance with the allowable ALE of 5.5 ppb. This poses a potential health and safety risk for 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:Claretta Yates
LICENSING EVALUATOR NAME:Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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