CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for one water outlet within the Facility. LPAs met with Nicole Botelho, director, and explained purpose of today's inspection to her. The lead testing was completed by Forensic Analytical Consulting Services on March 31, 2023. An Action Exceedance Level is a value of 5.5 parts per billion or greater. One water outlet (water faucet) - Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. Nicole states that the one water faucet was removed from service and drinking water is being provided only from drinking fountains that tested below the ALE value of 5.5 parts per billion. Nicole states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. The Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276) and updated Facility Sketch (LIC 999) were provided to LPA Matos prior to today's inspection. Exit interview conducted and report was reviewed with the Director, Nicole Botelho. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Nicole prior to the conclusion of today's inspection. Notice of site visit was issued and must remain posted for 30 days. SUPERVISORS NAME: Diana Stephenson LICENSING EVALUATOR NAME: Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 2 FACILITY NAME: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY FACILITY NUMBER: 434414559 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 06/05/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 07/05/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7Lead Testing Written Directives (b)(1) 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: 1 2 3 4 5 6 7Director states that the water faucet was removed from service and drinking water was provided only from drinking fountains that have tested below the ALE value of 5.5 parts per billion. 8 9 10 11 12 13 14Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. This poses a potential risk to the health, safety, and personal rights of children in care. 8 9 10 11 12 13 14Director states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. Nicole agreed to submit results of follow up lead testing to LPA by 07/05/23. 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Diana Stephenson LICENSING EVALUATOR NAME:Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for one water outlet within the Facility. LPAs met with Nicole Botelho, director, and explained purpose of today's inspection to her. The lead testing was completed by Forensic Analytical Consulting Services on March 31, 2023. An Action Exceedance Level is a value of 5.5 parts per billion or greater. One water outlet (water faucet) - Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. Nicole states that the one water faucet was removed from service and drinking water is being provided only from drinking fountains that tested below the ALE value of 5.5 parts per billion. Nicole states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. The Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276) and updated Facility Sketch (LIC 999) were provided to LPA Matos prior to today's inspection. Exit interview conducted and report was reviewed with the Director, Nicole Botelho. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Nicole prior to the conclusion of today's inspection. Notice of site visit was issued and must remain posted for 30 days. SUPERVISORS NAME: Diana Stephenson LICENSING EVALUATOR NAME: Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 2 FACILITY NAME: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY FACILITY NUMBER: 434414559 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 06/05/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 07/05/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7Lead Testing Written Directives (b)(1) 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: 1 2 3 4 5 6 7Director states that the water faucet was removed from service and drinking water was provided only from drinking fountains that have tested below the ALE value of 5.5 parts per billion. 8 9 10 11 12 13 14Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. This poses a potential risk to the health, safety, and personal rights of children in care. 8 9 10 11 12 13 14Director states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. Nicole agreed to submit results of follow up lead testing to LPA by 07/05/23. 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Diana Stephenson LICENSING EVALUATOR NAME:Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for one water outlet within the Facility. LPAs met with Nicole Botelho, director, and explained purpose of today's inspection to her. The lead testing was completed by Forensic Analytical Consulting Services on March 31, 2023. An Action Exceedance Level is a value of 5.5 parts per billion or greater. One water outlet (water faucet) - Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. Nicole states that the one water faucet was removed from service and drinking water is being provided only from drinking fountains that tested below the ALE value of 5.5 parts per billion. Nicole states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. The Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276) and updated Facility Sketch (LIC 999) were provided to LPA Matos prior to today's inspection. Exit interview conducted and report was reviewed with the Director, Nicole Botelho. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Nicole prior to the conclusion of today's inspection. Notice of site visit was issued and must remain posted for 30 days. SUPERVISORS NAME: Diana Stephenson LICENSING EVALUATOR NAME: Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 2 FACILITY NAME: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY FACILITY NUMBER: 434414559 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 06/05/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 07/05/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7Lead Testing Written Directives (b)(1) 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: 1 2 3 4 5 6 7Director states that the water faucet was removed from service and drinking water was provided only from drinking fountains that have tested below the ALE value of 5.5 parts per billion. 8 9 10 11 12 13 14Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. This poses a potential risk to the health, safety, and personal rights of children in care. 8 9 10 11 12 13 14Director states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. Nicole agreed to submit results of follow up lead testing to LPA by 07/05/23. 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Diana Stephenson LICENSING EVALUATOR NAME:Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for one water outlet within the Facility. LPAs met with Nicole Botelho, director, and explained purpose of today's inspection to her. The lead testing was completed by Forensic Analytical Consulting Services on March 31, 2023. An Action Exceedance Level is a value of 5.5 parts per billion or greater. One water outlet (water faucet) - Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. Nicole states that the one water faucet was removed from service and drinking water is being provided only from drinking fountains that tested below the ALE value of 5.5 parts per billion. Nicole states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. The Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276) and updated Facility Sketch (LIC 999) were provided to LPA Matos prior to today's inspection. Exit interview conducted and report was reviewed with the Director, Nicole Botelho. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Nicole prior to the conclusion of today's inspection. Notice of site visit was issued and must remain posted for 30 days. SUPERVISORS NAME: Diana Stephenson LICENSING EVALUATOR NAME: Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06/04)Page: 1 of 2 FACILITY NAME: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY FACILITY NUMBER: 434414559 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 06/05/2023 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 07/05/2023 Section Cited 101700.3(b)(1) 1 2 3 4 5 6 7Lead Testing Written Directives (b)(1) 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: 1 2 3 4 5 6 7Director states that the water faucet was removed from service and drinking water was provided only from drinking fountains that have tested below the ALE value of 5.5 parts per billion. 8 9 10 11 12 13 14Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion. This poses a potential risk to the health, safety, and personal rights of children in care. 8 9 10 11 12 13 14Director states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. Nicole agreed to submit results of follow up lead testing to LPA by 07/05/23. 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Diana Stephenson LICENSING EVALUATOR NAME:Melvin S Matos LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023