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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150407178
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:10:00 PM


Document Has Been Signed on 01/12/2023 12:10 PM - 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 SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:HORACE MANN ELEMENTARY SCHOOLFACILITY NUMBER:
150407178
ADMINISTRATOR:RUSSELL GAYERFACILITY TYPE:
850
ADDRESS:2710 NILES STREETTELEPHONE:
(661) 631-4936
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:24CENSUS: 11DATE:
01/12/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Storiann CampsTIME COMPLETED:
12:30 PM
NARRATIVE
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On 01/12/23 Licensing Program Analyst (LPA) Daniel Alvarez conducted an unannounced case management inspection. LPA Alvarez met with Coordinator Storiann Camps who accompanied LPA on a tour of the facility, and a census was taken. The purpose of today's inspection is to address the lead exceedance, referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at the facility.

The Fresno South Regional Office received notification of water lead exceedance at the facility resulting from a water lead sampling test collected on 11/21/2022. Records were reviewed from YES Environmental, Inc. and discussions with Coordinator Storiann Camps, it has been determined that there is an exceedance to outlets (B) and (D) in the facility. LPA Alvarez inspected outlet (B) it was observed to be a exterior water bottler filler that was impacted with 5.86ppb (ALE) of lead. LPA Alvarez also inspected outlet (D) it was observed to be a exterior drinking fountain that was impacted with 11.2ppb (ALE) of lead. Coordinator Storiann Camps stated the facility has made outlets (B) and (D) inoperable to preschool children by placing an "out of service" sign on the outlets. The outlets will not be used until the facility has received the results from a second water lead sampling test.

(See plan of correction for further corrective action 809D). Facility has already notified all the authorized representatives of this corrective action in English.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809D). An exit interview was conducted with Coordinator Storiann Camps.
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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Daniel Q AlvarezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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 01/12/2023 12:10 PM - 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 SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: HORACE MANN ELEMENTARY SCHOOL
FACILITY NUMBER: 150407178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
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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Per Coordinator affected outlet has been completely replaced, including all plumbing lines that lead to the outlet. Facility will conduct daily flushing for three weeks and will have a second water lead sampling test and notify Community Care Licensing (CCL) of results.
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Based on record review, two outlets at the facility contained 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 will notify all parents/authorized representatives of any corrective action already taken at the facility. Coordinator stated she will conduct a follow up water sample as outlined in Written Directives Section 101705 and submit all required documentation to CCL by 02/17/23.

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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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Daniel Q AlvarezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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