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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701117
Report Date: 02/08/2023
Date Signed: 02/08/2023 11:44:09 AM

Document Has Been Signed on 02/08/2023 11:44 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:EPISCOPAL COMMUNITY SERVICES - BOYS & GIRLS CLUBFACILITY NUMBER:
376701117
ADMINISTRATOR:DENISE TREJOFACILITY TYPE:
850
ADDRESS:1430 D AVENUETELEPHONE:
(619) 292-2550
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 24DATE:
02/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Denise TrejoTIME COMPLETED:
11:45 AM
NARRATIVE
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On 02/08/2023 at 10:30 AM, Dana Stevens made an unannounced CASE MANAGEMENT inspection, for reported Lead Exceedance. LPA met with Director Denise Trejo. Facility was within ratio & capacity. LPA interviewed Director and examined the water sources (spigots) deemed at Action Level Exceedance.

Spigots reported with 5.5 ppb or greater lead exceedance levels are as follows:

Kitchen sink spigot C (not for children use) 11.300 ppb
Classroom 1 spigot A 8.490 ppb
Classroom 2 spigot B 9.550 ppb

Director stated that spigots will be replaced and then flushed four times a day for 3 weeks. Director stated they will be retested in 3 - 4 weeks time. Director stated that spigots are not being used in any way for child care. All staff have been informed not to use spigots in exceedance for any reason. Bottled drinking water is being provided for children and staff.

See LIC809D for Type B deficiency cited.

Exit interview conducted. Appeal rights were discussed and given to director on this date. Notice of Site Visit was given to director and must be posted for 30 days.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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 02/08/2023 11:44 AM - It Cannot Be Edited


Created By: Dana Stevens On 02/08/2023 at 11:22 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: EPISCOPAL COMMUNITY SERVICES - BOYS & GIRLS CLUB
FACILITY NUMBER: 376701117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited

101700.3(b)(1)

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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 is not met as evidenced by:
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Spigots will be replaced and are not in use. Spigots will be routinely flushed as required. A second testing will be completed in three to four weeks and Director will provide LPA with the results.
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Based on water testing results and interview, facility tested over the Action Level Exceedance level at three water outlets (spigots). This may pose a 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:Cynthia Gray
LICENSING EVALUATOR NAME:Dana Stevens
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023


LIC809 (FAS) - (06/04)
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