330911138-1-6-2023-09-CC-GCAO-CMTV9U-20230106151456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 330911138
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:15:05 PM

Document Has Been Signed on 01/06/2023 03:15 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	IMMANUEL LUTHERAN PRESCHOOL		FACILITY NUMBER:	330911138
ADMINISTRATOR:	TRONA SALGADO		FACILITY TYPE:	850
ADDRESS:	5455 ALESSANDRO BLVD.		TELEPHONE:	(951) 682-4211
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	87	CENSUS: 64	DATE:	01/06/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Valerie Thompson		TIME COMPLETED:	03:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Due to required lead testing requirements, Licensing Program Analyst (LPA), Giselle Carbullido conducted a Case Management inspection based on lead testing results received on the facility. LPA Carbullido toured the facility, took census and met with Director, Valerie Thompson to further discuss lead results received and measures taken for remediation of lead exceedances.

During the inspection, LPA toured and obtained photos of the following water outlets identified with lead exceedances: Outlet C (20 ppb) which is located RM 1- Hippos; Outlet E (8.1 ppb) which is located RM 2 - Flamingos; Outlet G (12 ppb) which is located RM 3- Giraffes; Outlet I (11 ppb) which is located RM 4- Pandas; Outlet K (7.2 ppb) which is located RM 5 -Bees and Outlet L (14 ppb) which is located RM 6- Bears. LPA observed and obtained photos of required signage posted at outlets for cessation of use.
Facility implemented the following plan of action until formal remediation can be completed: All water outlets are covered, sealed with posted signage for nonuse. Facility's outlets C,G,I,E,K are classroom drinking fountains; these rooms have additional faucets for access to water. Outlet L is a faucet and there is a drinking fountain for additional access to water. Facility is currently in process for repair and considering removal of all drinking fountains and replacing with filtered water. LPA observed notification of lead results posted at the facility entry- front doors.

Photos also obtained of additional source for access to water: Additional faucets in each classroom.

Due to facility water outlets testing above approved lead levels, a deficiency has been cited. See LIC809D.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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 3

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: IMMANUEL LUTHERAN PRESCHOOL	FACILITY NUMBER: 330911138
	VISIT DATE: 01/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Additionally, the following resources were discussed and provided from PIN 21-21.1- CCP dated December 28, 2022:
101700.6 Grant Funding for Qualifying Child care Centers

(a) Senate Bill 862, Chapter 449, Statutes of 2018 allocated $5 Million to the State Water Resources Control Board for testing and remediation of lead in the drinking water of Child Care Centers based on the following criteria:

(1) Those that serve children zero to five years of age, with the highest priority for Child Care Centers that provide care for children zero to three years of age.

(2) Those that have 50 percent or more of their registered children who receive subsidized care.

(3) Those that operate only one facility.

(b) To determine a Child Care Center’s eligibility for possible funding the Department will provide access to a link to an online eligibility form located on the Department’s website and on Sacramento State’s Office of Water Programs website.

(1) A Child Care Center interested in financial assistance shall complete the eligibility form, which shall include instructions for completing and returning it, prior to receiving any grant funding for which it may qualify. To determine a Child Care Center’s eligibility for possible funding, the provider will need to complete an online eligibility form available at Office of Water Programs’ website

An exit interview was conducted, and appeal rights discussed. LPA Carbullido provided Valerie Thompson, Director with a copy of this report, appeal rights and notice of site visit. This report must be made available to the public upon request for three years.

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 01/06/2023 03:15 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: IMMANUEL LUTHERAN PRESCHOOL	FACILITY NUMBER: 330911138
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/06/2023 Section Cited	1 2 3 4 5 6 7	California Lead Action Level at Child Care Centers 101700.3 (b)(1): A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will implement corrective action pursuant to section CCR 101704 for immediate cessation of outlets testing with action level exceedance until it is replaced and retested pursuant to section CCR 101705 and returns a result at or below the Acton level. Facility will notify CDSS with completion within 30 days.
	8 9 10 11 12 13 14	Based on records review of required lead testing, the facility had lead values of 5.5 or above on water outlets: C (20 ppb); E (8.1 ppb); G (12 ppb); I (11 ppb); K (7.2 ppb) and L (14 ppb). This is a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Gilbert Sena	TELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Giselle Carbullido	TELEPHONE: (951) 970-1904
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3