500316978-9-8-2022-04-CC-AGIN-CJ3Q59-20220908115130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 500316978
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:51:41 AM

Document Has Been Signed on 09/08/2022 11:51 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	SHACKELFORD ELEMENTARY		FACILITY NUMBER:	500316978
ADMINISTRATOR:	NUNES, HEIDI		FACILITY TYPE:	850
ADDRESS:	100 SCHOOL AVENUE		TELEPHONE:	(209) 574-8422
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	24	CENSUS: 5	DATE:	09/08/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Aaron Castro		TIME COMPLETED:	12:00 PM

NARRATIVE

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On 09/08/22 Licensing Program Analyst (LPA) Araceli Gibson conducted an unannounced case management inspection. LPA met with Aaron Castro, Supervisor of Environmental Health and Safety and Hiedi Nunez Senior Director ECE. Purpose of today's inspection is to conduct a case management inspection regarding a water lead exceedance referred to as Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the drinking water at the Shackelford Elementary Preschool facility 500316978.

Fresno Regional Office received notification of water lead exceedance at the facility used for drinking and or food preparation. Based on records reviewed provided by Aaron produced by Forensic Analytical Consulting Services, Inc. for facility 500316978 there was a result of (ALE) of 5.8 for outlet D. Licensee proceeded with follow up and repair. On 08/16/22 Outlet D was resampled and returned at an Action Level of 5.4 ppb, which is out of compliance over the allowable Action Level 5 ppb.

Per Directives in PIN 21-21 CP 101700.3 California Lead Action Level at Child Care Centers (a) California’s Action Level for lead in water at Child Care Centers is 5 ppb. (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. (c) If testing indicates an Action Level Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response pursuant to section 101704 shall be required.

101704 Lead Action Level Exceedance Response Requirements (a) If a drinking water outlet test results in an Action Level Exceedance, the use of that outlet for drinking and food preparation purposes shall immediately cease until it is replaced and retested pursuant to section 101705 and returns a result at or below the Action Level.

Continued 809C

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SHACKELFORD ELEMENTARY	FACILITY NUMBER: 500316978
	VISIT DATE: 09/08/2022

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A plan of correction Type B citation was issued to ensure the safety and well-being of children, employees and visitors. The use of Outlet D shall not be in use until it can be repaired or permanently capped off. Aaron agrees on repairs and installing filter to the water source which impact both outlet E and D. Filters will be maintained by maintenance at the facility. An alternate source of drinking water is available for consumption at the facility. Authorized Representative were notified on 05/18/22. (See Plan of correction for further corrective action 809D).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, (see next page, 809 D). LPA provided a copy of appeal rights. An exit interview was conducted. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2022 11:51 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: SHACKELFORD ELEMENTARY	FACILITY NUMBER: 500316978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/07/2022 Section Cited	1 2 3 4 5 6 7	101700.3 California Action Level at Child Care Centers. (b)Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
	8 9 10 11 12 13 14	This requirement was not met evidence by: Based on record review provided by Forensic Analytical Consulting Services, Inc. for facility 500316978 a result of (ALE) of 5.8 for outlet D. Follow up on 08/16/22 Outlet D returned at an Action Level of 5.4 ppb, out of compliance over the allowable Action Level 5 ppb. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Aaron agrees on repairs and installing filter to the water source which impact both outlet E and D. Filters will be maintained by maintenance at the facility. An alternate source of drinking water is available for consumption at the facility. Authorized Representative were notified on 05/18/22.
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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: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli Gibson	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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