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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313621978
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:48:03 PM


Document Has Been Signed on 11/10/2022 01:48 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:STAR CARLIN C. COPPINFACILITY NUMBER:
313621978
ADMINISTRATOR:ASHLEIGH WEATHERLYFACILITY TYPE:
840
ADDRESS:150 E. 12TH STREETTELEPHONE:
(916) 632-8407
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:60CENSUS: DATE:
11/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rachel Peters and Ashleigh WeatherlyTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Blesi and Gallo met with the facility representative, Ashleigh Weatherly and Rachel Peters, for a case management inspection. The purpose of the inspection was to discuss the lead in facility water report.

During today's inspection, LPA discuss the report with the facility representative. LPA explained to the facility representative that all faucets that are used for drinking or cooking, must have less than 5.5 PPB lead. The facility had water tested on October 7, 2022 and it was found that in one of the tested faucet had 6.0 PPB lead in the water. The facility representative stated that the facility has not been using the faucet for drinking and supplies bottle water since the day results came in. LPA observed the faucet in the classroom, which exceeded the requirement. Staff have placed a sign above the faucet stating the sink is to be used for hand washing only and not for drinking.

See next page for deficiency cited today. Copy of this report was reviewed and provided to the facility representative. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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 11/10/2022 01:48 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: STAR CARLIN C. COPPIN
FACILITY NUMBER: 313621978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2022
Section Cited

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California Lead Action Level at Child Care Centers. b) Testing results with fractional ppb readings of 0.5 or greater shall be rounded up to the nearest whole number, before comparing to the Action level. 1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not
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met as evidenced by based on results of a test conducted on a faucet on October 7, 2022 indicated 6.0 ppb in the faucet water, which exceed 5.5 ppb requirement. This is a potential risk to the health and safety of 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: Amanda BlesiTELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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