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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620780
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:21:26 PM


Document Has Been Signed on 01/18/2023 01:21 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:DON AVENUE EARLY CARE AND LEARNING CENTERFACILITY NUMBER:
393620780
ADMINISTRATOR:MADRIGAL, MAYRAFACILITY TYPE:
830
ADDRESS:8121 DON AVENUETELEPHONE:
(209) 951-5201
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:12CENSUS: 13DATE:
01/18/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mayra MadrigalTIME COMPLETED:
01:45 PM
NARRATIVE
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On 01/18/23, Licensing Program Analyst (LPA) Elvira Sierra met with Director, Mayra Madrigal, to conduct an unannounced case management inspection. The purpose of the inspection was to follow up on a water sampling related to lead in drinking water and food preparation water used at child care centers. There were 6 staff present supervising 13 children.

The Regional Office was notified that the lead testing results indicated an Action Level Exceedance (ALE) for a drinking fountain (Outlet C) located in classroom #2 which was tested on 12/16/22. On 01/12/23, the facility was notified that water levels in Outlet C were in exceedance of 5.5 parts per billion (ppb). Director stated Outlet C has not been used for years for water consumption. Outlet C drinking fountain was removed and capped off. Sink will be only be used to wash hands. Director stated facility uses a local water dispenser for drinking purpose. LPA verified the affected water outlet was removed and inoperable and observed alternative drinking water available within the facility.

A deficiency is being cited on the attached LIC 809-D page.

An exit interview was conducted and report was reviewed with the Director, Mayra Madrigal. A notice of site visit was posted and must remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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 01/18/2023 01:21 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: DON AVENUE EARLY CARE AND LEARNING CENTER
FACILITY NUMBER: 393620780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited

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101700.3 California Lead Action Level at Child Care Centers (b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This requirement was not met as evidenced by:
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Director stated the affected water outlet has not been used for water consumption for years. The outlet is not being used for water consumption and the drinking fountain was removed and capped off. Director stated facility uses water dispensers for drinking and food preparation. Gallons of water are delivery every two weeks to the facility.
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Based on record review, the lead testing results indicated an Action Level Exceedance for a drinking fountain located in classroom #2 outlet C which was tested on 12/16/22. This poses a potential health, safety, or personal rights risk to children in care.
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LPA received sample cheklist and self certification forms and facility sketch indicating afected outlet in the classroom. LPA observed affected outlet was capped on and drinking fountain was removed on today's inspection.

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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: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2