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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 290310525
Report Date: 02/14/2023
Date Signed: 02/14/2023 11:44:57 AM


Document Has Been Signed on 02/14/2023 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:COUNTRY PRESCHOOL, THEFACILITY NUMBER:
290310525
ADMINISTRATOR:REISWIG, PATSYFACILITY TYPE:
850
ADDRESS:10515 ALTA STREETTELEPHONE:
(530) 273-8693
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:60CENSUS: 28DATE:
02/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lynette BulickTIME COMPLETED:
11:40 AM
NARRATIVE
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On February 14, 2023, at approximately 10:00 AM Licensing Program Analyst (LPA) Matthew Gallo met with facility representative Lynette Bulick to conduct an unannounced case management inspection to address a lead exceedance received by the Department. Director Patsy Reiswig was also present. Upon arrival, LPA observed 28 preschool children in care supervised by 4 staff. The purpose of today's inspection is to create a plan of correction following reports of lead exceedance in outlets tested in the facility.

Assembly Bill (AB) 2370, Chapter 676, Statues of 2018, requires all Child Care Center (CCC) licensee with facilities built before January 1, 2010, to test their water outlets used for drinking and food preparation. On 12/30/2022, the facility tested water samples for lead. Results received by the Licensing office showed an exceedance measuring 5.97 ppb.

Representative Bulick states that since the test results they have forbidden the faucet from being used for anything but handwashing by staff, and LPA observed signs over faucet with the warning Facet is NOT to be used for drinking or food prep. Washing hands only" alongside copies of lead exceedence report. A separate, cleared drinking faucet in the room is currently used for alternative water consumption. Bulick stated and showed confirmation that further testing would occur on 2/23/2023.

A deficiency is cited on the following LIC809-D and a plan of correction was created with the facility representative, Lynette Bulick, who reviewed this report and was provided Appeal Rights and Notice of Site Visit by LPA.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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 02/14/2023 11:44 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: COUNTRY PRESCHOOL, THE
FACILITY NUMBER: 290310525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited

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California Lead Action Level at Child Care Centers (b) Testing results with ... (1) ... "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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To correct the deficiency, facility will continue to not use the faucet for drinking or food preparation and keep their warning posted. LPA will follow up with director/owner after results of 2/23/23 test are obtained to ensure compliant ppb levels and that affected outlets have been repaired or replaced
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Record review shows one water outlet tested in exceedance of the allowed 5.5 ppb, which poses a potential 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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
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