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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300407
Report Date: 03/21/2022
Date Signed: 03/21/2022 01:14:47 PM


Document Has Been Signed on 03/21/2022 01:14 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:LITTLE METHODIST SCHOOLFACILITY NUMBER:
340300407
ADMINISTRATOR:JAS, SUEFACILITY TYPE:
850
ADDRESS:9849 FAIR OAKS BLVDTELEPHONE:
(916) 961-0368
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:70CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sue JasTIME COMPLETED:
01:30 PM
NARRATIVE
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On Monday March 21, 2022 at 12:30 pm LPAs L. Habtom and A. Blesi arrived at Little Methodist School for an unannounced case management visit. There were no children present during today's visit. LPAs met with director Sue Jas to address the lead level results in excedance of 5 parts per billion for all 9 water faucets and fountains tested. Water samples were taken on December 20, 2021 and results were provided to assigned analyst LPA L. Habtom on March 14, 2022. Director Sue stated prior to receiving the results the faucets and fountains were not being used. Director Sue explained that children bring their own labeled water bottles. Extra water bottles are kept at the center in the supply room. The centers operating hours is 9 am- 12 pm with one snack being provided. If any food has to be washed, the director rinses it at home or uses water bottles at the center. Sue is working to determine the results of the lead levels in order to get the water at the standard acceptable levels. Sue will keep LPA L. Habtom informed of the outcome, time frame and work needed in order to be in compliance with the lead levels. During today's visit, Sue made all water fountains inoperable by either shutting off the water supply or placing a bag over the fountain. Director was notified to only use water faucets at the center to wash hands and art supply until otherwise notified.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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 03/21/2022 01:14 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: LITTLE METHODIST SCHOOL
FACILITY NUMBER: 340300407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited

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Physical, Plant, Building & Grounds: 101238(a):
The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement was not met as evidenced by:
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Lead results which were in excedance of the standard level considered safe of 5 parts per billion,
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Sue made all water fountains inoperable by either shutting off the water source or placing a bag over the fountains. Long term results will be communicated to LPA L. Habtom.

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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: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2