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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393614190
Report Date: 03/20/2023
Date Signed: 03/20/2023 02:48:20 PM


Document Has Been Signed on 03/20/2023 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:TRACY UNIFIED SCHOOL DISTRICT - NORTH PRESCHOOLFACILITY NUMBER:
393614190
ADMINISTRATOR:REBECCA SILVAFACILITY TYPE:
850
ADDRESS:2875 HOLLY DRIVE #P-1TELEPHONE:
(209) 832-6768
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:24CENSUS: 19DATE:
03/20/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Rebecca Silva TIME COMPLETED:
03:00 PM
NARRATIVE
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On March 20, 2023, Licensing Program Analyst (LPA) Stacey Williams met with School Readiness Lead, Rebecca Silva for an unannounced Case Management Inspection. LPA observed 19 children being cared for by 4 staff members.

The purpose of today’s inspection was to follow up regarding a water sampling that indicated Action Level Exceedances (ALEs) in one outlet that was tested for lead levels on 2/15/2023. On 03/6/2023 the facility was notified that water levels were in exceedance of 5 parts per billion in drinking fountain (fixture A). Fixture A is located in the primary classroom associated with license #393614190. All exceedances are being addressed in this report.

Since receiving the notification School Readiness Lead advised that the water fountain in Fixture A has not been in use since April of 2021. Fixture A was permanently ceased and removed. Children bring their own water. Water is replenished by way of usage of bottled water.

LPA informed School Readiness Lead that Grant funding for testing and remediation is available and information can be found in Provider Information Notice (PIN) 21-04-CCP.

A Type B deficiency was cited on the subsequent page (LIC809-D) of this report.

An Exit interview conducted, and the report was reviewed and provided to School Readiness . LPA posted the Notice of Site Visit and Director acknowledges it must remain posted for 30 days. A Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/20/2023 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: TRACY UNIFIED SCHOOL DISTRICT - NORTH PRESCHOOL
FACILITY NUMBER: 393614190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2023
Section Cited

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101700.3 California Lead Action Level at Child Care Centers (c) If testing indicates an...Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response...shall be required. This requirement was not as evidenced by:
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LPA observed that outlet A has been permanently ceased and removed. School Readiness Lead has also advised that outlet A has not been used since April of 2021.
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Lead test results received by Licensing on 03/15/2023, tested on 2/15/2023, showed outlet A in the facility with lead levels exceeding 5 parts per billion (ppb). This poses a potential risk to the health and safety of children 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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2