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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621652
Report Date: 03/01/2023
Date Signed: 03/01/2023 11:36:55 AM


Document Has Been Signed on 03/01/2023 11:36 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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:COUNTRY CLUB EARLY CARE & LEARNING CENTERFACILITY NUMBER:
393621652
ADMINISTRATOR:APRIL BETHARDSFACILITY TYPE:
850
ADDRESS:2448 COUNTRY CLUB BOULEVARDTELEPHONE:
(209) 941-9100
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:72CENSUS: 38DATE:
03/01/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Veronica GonzalezTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) David Nguyen and Lauren Scott met with director, Veronica Gonzalez for a Case Management inspection. The purpose of the inspection was to follow-up on a lead testing report, which tested the water in the facility for lead levels.

LPA was notified of the lead testing report on 12/14/2022 via email. The report revealed that one water outlet in room 2 had elevated levels of lead (6.5ppb). During today's inspection, LPA's observed that the fountain has been removed. LPA's observed a water pitcher and cups that are being used inside and outside for children to consume water.

As a result of the water testing positive for lead, a deficiency was cited on a subsequent page, LIC 809D. An exit interview was conducted and the report was reviewed with director, Veronica Gonzales. A Notice of Site was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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 03/01/2023 11:36 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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: COUNTRY CLUB EARLY CARE & LEARNING CENTER
FACILITY NUMBER: 393621652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2023
Section Cited

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Lead Testing (b)(1) A result which 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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During today's visit LPAs observed that the affected water outlet was removed and Facility is providing water in a water pitcher with cups to children
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The water report revealed that the facility had elevated levels of lead in one water fountain in room 2 at 6.5ppb. This is a potential health and safety risk to the 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: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2