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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318296
Report Date: 01/10/2023
Date Signed: 01/10/2023 09:09:00 AM


Document Has Been Signed on 01/10/2023 09:09 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:HAGGINWOOD STATE PRESCHOOLFACILITY NUMBER:
340318296
ADMINISTRATOR:SYMON, TANISHAFACILITY TYPE:
850
ADDRESS:1418 PALO VERDE AVENUE, RM. 20TELEPHONE:
(916) 566-3475
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:22CENSUS: 5DATE:
01/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tanisha SymonTIME COMPLETED:
09:25 AM
NARRATIVE
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On January 10, 2023, at approximately 8:30 AM Licensing Program Analyst (LPA) Alize Tillery met with Director Tanisha Symon to conduct an unannounced case management inspection. During today's inspection there were 5 preschool children, supervised by 2 staff. The purpose of today's inspection was to create a plan of correction following reports of lead exceedance in two outlets.

A test result showing an amount of 5.5ppb, or over, is considered an Lead Action Level Exceedance. On 12/6/2022, the facility tested water samples for lead. Two water outlets sampled indicated an Action Level Exceedance (ALE). These outlets were marked L and J on the facility's sketch. Outlet L has an exceedance of 13ppb and outlet J with an exceedance of 9.2ppb.

During today’s inspection, LPA did not have the sketch to determine which outlets were marked L and J. Director is not familiar with the sketch but will access it, to provide to LPA Tillery. Director stated that the cafeteria provides the children's meals and for drinking water they have filtered water jugs delivered. Director stated that she does not believe the preschool children have access to faucets L and J.

A deficiency is cited on the following LIC809-D and a plan of correction was created with the Director, Tanisha Symon. A copy of this report and appeal rights were provided to the Director.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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 01/10/2023 09:09 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: HAGGINWOOD STATE PRESCHOOL
FACILITY NUMBER: 340318296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited

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

This requirment was not met, based on results received that showed water outlet L and J with a lead exceedance over 5.5ppb.
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Director will send to LPA Tillery the facility sketch with labeled outlets. LPA will return to clear the deficiency.

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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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