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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318126
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:52:40 PM


Document Has Been Signed on 04/06/2023 12:52 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:PRAIRIE ELEMENTARYFACILITY NUMBER:
340318126
ADMINISTRATOR:KEVAL, FAWZIAFACILITY TYPE:
850
ADDRESS:5251 VALLEY HI DRIVETELEPHONE:
(916) 399-1050
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:118CENSUS: 62DATE:
04/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tiffanee JohnsonTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gagandeep Singh met with vice principal, Tiffanee Johnson, for a case management inspection because of the water testing done at the facility. Purpose of the inspection was explained.

The facility had the water test conducted on March 08, 2023 for the lead. Based on the report, faucet labeled A had 11 PPB, faucet labeled D had 7.9 PPB and faucet labeled H had 6.9 PPB lead in the water. LPA dicussed with vice principal that the Department's requirements are that the findings must be lower than 5.5 PPB. Vice principal stated that the facility is not using that faucet for drinking anymore. The facility is using the water dispenser with filter and bottled water for drinking water.

Copy of this report was reviewed and provided to the vice principal. See next page for written directive provided today. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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 04/06/2023 12:52 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: PRAIRIE ELEMENTARY
FACILITY NUMBER: 340318126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
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.
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Vice principal stated that the facility is not using the faucet labeled A,D and H for drinking. Per Vice principal, facility is using bottled water as drinking water for children in care.
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This requirement is not met as evidenced by: Based on results of a test conduct on faucets on March 08, 2023, indicated three faucets exceeded 5.5 ppb requirement. This is a potential risk to the health and safety of children in care if not corrected.
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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: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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