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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 255406110
Report Date: 03/15/2024
Date Signed: 03/15/2024 02:10:13 PM


Document Has Been Signed on 03/15/2024 02:10 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:TULELAKE PRESCHOOLFACILITY NUMBER:
255406110
ADMINISTRATOR:CHAVEZ, VERONICAFACILITY TYPE:
850
ADDRESS:461 2ND ST.TELEPHONE:
(530) 233-7166
CITY:TULELAKESTATE: CAZIP CODE:
96134
CAPACITY:38CENSUS: 12DATE:
03/15/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Veronica Chavez - Head Teacher TIME COMPLETED:
02:20 PM
NARRATIVE
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On 3/15/24 at 1:50pm, Licensing Program Analyst (LPA) Tammy Dutra & Sydney Sims made a case management inspection and met with Veronica Chavez. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucets tested above the allowable level (5.5 ppb or greater) of lead in the water:

Faucet “F” – Main Classroom Sink - 18.8ppb

The facility has made the faucet inaccessible by creating a sign that says " Do Not Use" and the sink's faucet is bagged off making it inaccessible. The facility has replaced the faucet and plans to retest the fauce Ft. Children in care are receiving drinking water from bottled water.

The following deficiency is being cited: Faucet F testing over lead exceedance. (see LIC 809D).

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Head teacher Veronica Chavez .
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Tammy DutraTELEPHONE: (530) 806-3471
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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 03/15/2024 02:10 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: TULELAKE PRESCHOOL
FACILITY NUMBER: 255406110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
HSC
101700.3(b)(2)

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101700.3(b)(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care
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The facility has made the faucets temporarily inaccessible by do not use sign and bagging the faucet. The facility has replaced the faucet and will create a plan with a time line to retest for lead exceedences and send copy of plan to LPA Tammy Dutra by 03/29/24
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This requirement was not met as evidenced by:
Based on record review, the facility had 1 fauce with lead test results exceeding 5 ppb of lead in the water. This is a potential health and safety 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: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Tammy DutraTELEPHONE: (530) 806-3471
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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