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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616142
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:48:11 PM


Document Has Been Signed on 09/28/2023 02:48 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SJUSD - FAIR OAKS ANNEXFACILITY NUMBER:
343616142
ADMINISTRATOR:MCMANNIS, DEBBIEFACILITY TYPE:
830
ADDRESS:10700 FAIR OAKS BLVD.TELEPHONE:
(916) 971-5837
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:16CENSUS: 8DATE:
09/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joyce RothTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Michelle Perez met with Joyce Roth, to conduct an unannounced case management inspection regarding lead testing. During today's inspection there was a census of 8 school aged children with four staff. The purpose of today's inspection was to create a plan of correction following reports of lead exceedance in a few of the facility outlets.

On 07/18/2023, the facility tested water samples for lead. The lead testing identified that two water outlets have lead exceedance over the amount of 5.5ppb.

The water outlet sampled is identified as letters, B and C and is located in the infant facility. Water outlet B had a lead measurement of 5.7 PPB and outlet C had a measurement of 7.7 PPB.

Upon inspection today, LPA observed that faucets C and B had been replaced and facility is awaiting a reinspection. Faucets are not currently in use for water consumption until they are reinspected. Water consumption is from the kitchen faucet.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Michelle PerezTELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142
VISIT DATE: 09/28/2023
NARRATIVE
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Deficiencies are cited in the report and are considered a potential threat to the health and safety of children in care, if not corrected.

An exit interview was conducted with the Director. LPA provided Director with Appeal Rights. A Notice of Site Visit was provided and must be posted for 30 days along with the lead results for parental review.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Michelle PerezTELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/28/2023 02:48 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2023
Section Cited
CCR
101700.3(b)(1)

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California Lead Action Level at Child Care Centers (b) Testing results with ... (1) A ... values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidenced by:
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Facility has replaced both faucets, labeled B and C and will schedule a reinspection ASAP.
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Based on record review, sample site B had a measure of 5.5PPB and sample site C measured 7.7PPB. This exceeded the allowed 5.5 ppb, which poses/posed 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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Michelle PerezTELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3