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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100407360
Report Date: 01/10/2023
Date Signed: 01/10/2023 09:58:02 AM


Document Has Been Signed on 01/10/2023 09:58 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:CHILD DEVELOPMENT-STATE PRESCHOOL-PINEDALEFACILITY NUMBER:
100407360
ADMINISTRATOR:TARA LOGANFACILITY TYPE:
850
ADDRESS:7171 N. SUGARPINETELEPHONE:
(559) 327-7786
CITY:PINEDALESTATE: CAZIP CODE:
93650
CAPACITY:26CENSUS: 13DATE:
01/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Monica LeavittTIME COMPLETED:
10:00 AM
NARRATIVE
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On 01/10/2023 Licensing Program Analyst (LPA) Jeovanna Yanez conducted an unannounced case management inspection. LPA met with Teacher, Monica Leavitt, who accompanied LPA on a tour of the facility. The purpose of today’s inspection is to address a lead exceedance referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) from water at the facility.

Fresno Regional Office received notification that the facility has a high lead exceedance from a water lead sampling test collected on 12/16/22. Based on records reviewed from the CA Water Board Data Management System, and self-reported information from the facility, one faucet (PRESCHOOL CLASS FOUNTAIN) shows an ALE of 11.7 ppb. Based on documentation submitted and LPA's observation, the facility has made the outlet inoperable, and has already submitted a work order to permanently remove the outlet with a Certified Sampler. The facility is providing alternative potable water via Valley Springs Water Service to children, visitors, and staff during hours of operation. Parents/authorized representatives have been notified of the ALE and any corrective action being taken, and results of the lead testing results have been posted on the parent board. Licensee submitted the following documents along with the incident report: Facility Sketch (LIC 999) for both indoor and outdoor areas, Child Care Center Sampling Checklist form (LIC 9276), External Water Sampler Self-Certification Form (LIC 9275), Lead testing results for the facility, from LA Testing, Pictures of faucets/fountains being tested. The facility has agreed to continue with permanently removing the outlet.


Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D). Licensee was provided a copy of appeal rights. An exit interview was conducted with the Teacher.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Jeovanna YanezTELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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


Document Has Been Signed on 01/10/2023 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: CHILD DEVELOPMENT-STATE PRESCHOOL-PINEDALE
FACILITY NUMBER: 100407360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2023
Section Cited

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California Action Level at Child Care Centers (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number ... (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance (ALE). This requirement was not met as evidenced by:
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Facility has ceased operation of the affected water outlet and made the outlet inoperable. Updated plan of operation with changes to the facility has already been submitted. Facility has already notified parents/authorized representatives of corrective action already taken. Facility offers alternative potable water.
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Based on record review and observation, one outlet at the facility contained a lead exceedance greater than 5.5 ppb. This poses a potential health, safety or personal rights risk to persons in care.
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Facility has placed a work order to remove the outlet and will submit documentation of the outlet removed to CCL by POC Due Date.

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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: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Jeovanna YanezTELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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