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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910778
Report Date: 04/17/2023
Date Signed: 04/17/2023 11:09:26 AM


Document Has Been Signed on 04/17/2023 11:09 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:JUSD/INA ARBUCKLE ELEMENTARYFACILITY NUMBER:
330910778
ADMINISTRATOR:KATRINA BROOKSFACILITY TYPE:
850
ADDRESS:3600 PACKARD STREETTELEPHONE:
(951) 222-7850
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY:48CENSUS: 10DATE:
04/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Katrina Brooks, ECE CoordinatorTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kay Turner and Raymond Moorehead, Jr arrived at the facility to conduct a case management visit regarding the lead testing. LPA met with the ECE Coordinator, Katrina Brooks, and explained the purpose for today's visit. LPA toured the center and a census was taken.

On 03/14/2023, lead testing was completed of the water sources at the facility. The kitchen sink located in classroom 35 at the facility tested at the exceedance level of 6.2. Classroom 35 has not been in operation since May 2022 and is not scheduled to reopen during this school year. The facility is operating out of classroom 36, where all of the water sources tested were below the exceedance level. The old faucet fixtures of the kitchen sink in classroom 35 were removed and replaced; retesting is scheduled to be completed by Friday, 04/28/2023. The aforementioned resulted in a deficiency, as the documented lead levels exceeded 5.5 ppb and is above the level of exceedance per the Lead Testing Written Directives. Please see 809D for deficiency.

Exit interview conducted and report was reviewed with the ECE Coordinator, Katrina Brooks.

A copy of this report and appeal rights were provided to the ECE Coodinator. In addition,a Notice of Site Visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene TurnerTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
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 04/17/2023 11:09 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: JUSD/INA ARBUCKLE ELEMENTARY
FACILITY NUMBER: 330910778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2023
Section Cited

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(b)(1), A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. 

This requirement was not met as evidenced by...


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The kitchen faucet fixture in classroom 35 were removed and replaced. The water sampling retest is scheduled for next week by Friday 04/28/2023. Upon completion of the retest, the results will be submitted to the LPA.
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Per the lead sample report completed on 03/17/2023, the kitchen sink located in classroom 35 at the facility lead test results were 6.2 UG/L, at the action level of exceedance. This poses a potential health, safety or personal rights risk to persons 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: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene TurnerTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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