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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005166
Report Date: 02/15/2023
Date Signed: 02/15/2023 09:39:18 AM

Document Has Been Signed on 02/15/2023 09:39 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:JEWISH COMMUNITY CENTER; M. LARRY LAWRENCE BRANCHFACILITY NUMBER:
372005166
ADMINISTRATOR:FRAN FORMANFACILITY TYPE:
850
ADDRESS:4126 EXECUTIVE DRIVETELEPHONE:
(858) 362-1171
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 241TOTAL ENROLLED CHILDREN: 241CENSUS: DATE:
02/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:TIME COMPLETED:
09:50 AM
NARRATIVE
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On 2/15/2023 at 8:43AM, Licensing Program Analyst (LPA), Nancy Diaz conducted an unannounced case management inspection for the Action Level Exceedance (ALE) of lead detected in facility water fixture. LPA met with facility representative, Fran Forman. The purpose of the inspection was explained and facility was toured. Present in facility were 91 children and 24 staff members.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with facility director during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

LPA obtained copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276) Facility Sketch (LIC999) today.

On 01/13/2023 the Department received notification from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 1/03/2023. The outlets/fixtures reported with 5.5 ppb or greater lead exceedance levels were as follows:

Location G - lead exceedance was 6.400 pbb located outside Room #7. The outlet was removed after facility was notified of result of the study.

Grant funding will be available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information, including additional resources please visit https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: JEWISH COMMUNITY CENTER; M. LARRY LAWRENCE BRANCH
FACILITY NUMBER: 372005166
VISIT DATE: 02/15/2023
NARRATIVE
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Type B deficiency was cited today. Type B deficiency if not corrected poses a potential risk to the health, safety or personal rights of children in care.

Exit interview conducted and report was reviewed with facility representative, Fran Forman. A copy of this report, along with Appeal Rights (LIC9058), were provided. A notice of site visit was given and must remain posted for 30 days. LPA observed that the notice of site visit was posted during the inspection. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
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Document Has Been Signed on 02/15/2023 09:39 AM - It Cannot Be Edited


Created By: Nancy Diaz On 02/15/2023 at 09:22 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: JEWISH COMMUNITY CENTER; M. LARRY LAWRENCE BRANCH
FACILITY NUMBER: 372005166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) Written Directives per AB2370: A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by…

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OBSERVED CORRECTED. Facility took out the outlet immediately after notification of lead exceedance.
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Based on water testing results and interviews, facility tested over the Action Level Exceedance level for location G (outside Room #7). This outlet was never used for drinking as facility provided water via Sparklets delivered at school. This posed a potential health, safety or personal rights risk to 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:Tashima Daniel
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023


LIC809 (FAS) - (06/04)
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