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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364815524
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:01:29 PM


Document Has Been Signed on 02/03/2023 01:01 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:FUSD-DOROTHY GRANT ELEMENTARYFACILITY NUMBER:
364815524
ADMINISTRATOR:DARCY WHITNEYFACILITY TYPE:
850
ADDRESS:7069 ISABEL LANETELEPHONE:
(909) 357-5540
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:24CENSUS: 19DATE:
02/03/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Darlene Johnson WoodsTIME COMPLETED:
01:05 PM
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Due to required lead testing requirements, Licensing Program Analyst (LPA), Justin Giese conducted a Case Management inspection based on lead testing results received from the facility. LPA toured the facility, took census and met with Permit Teacher, Darlene Johnson Woods 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 outlet identified with lead exceedances: Outlet C (8.3 ppb) which was identified as food prep/hand washing sink located in the off site Kitchen within the elementary school cafeteria.

LPA observed and obtained photos of required signage posted at the outlet for cessation of use.

Outlet C was identified as food prep/hand washing sink located in the off site Kitchen within the elementary school cafeteria. Facility implemented the following plan of action until formal remediation can be completed: LPA was informed by facility staff that the faucet identified as location C, was replaced but still currently out of use. The water outlet will then be re-tested for exceedances at a later date. The identified water outlet has been covered and sealed with posted signage for non-use. The facility has additional sinks and faucets for food prep/hand washing in the off site Kitchen within the elementary school cafeteria.

Facility is currently in the process of having outlet C re-tested. Additionally, LPA observed notification of lead results posted at the facility entry.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: FUSD-DOROTHY GRANT ELEMENTARY
FACILITY NUMBER: 364815524
VISIT DATE: 02/03/2023
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Due to water outlet C testing above approved lead levels, a deficiency has been cited. See LIC809D for Type B Deficiency.

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 provided Permit Teacher, Darlene Johnson Woods with a copy of this report and notice of site visit.

This report must be made available to the public upon request for three years.

SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/03/2023 01:01 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: FUSD-DOROTHY GRANT ELEMENTARY
FACILITY NUMBER: 364815524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited

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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:
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Facility will implement corrective action pursuant to section CCR 101704 for immediate cessation of outlets testing with action level exceedance until it is replaced, removed or 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.
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Based on records review of required lead testing, the facility had lead values of 5.5 or above on water outlet C (8.3 ppb)



This is a potential health and safety 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: Gilbert SenaTELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin GieseTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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