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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503603196
Report Date: 03/07/2023
Date Signed: 03/07/2023 11:22:27 AM


Document Has Been Signed on 03/07/2023 11:22 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:MONTESSORI SCHOOL OF MODESTOFACILITY NUMBER:
503603196
ADMINISTRATOR:SEGURA, EVAFACILITY TYPE:
850
ADDRESS:3501 SAN CLEMENTE AVE.TELEPHONE:
(209) 567-1115
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:140CENSUS: DATE:
03/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eva SeguraTIME COMPLETED:
11:30 AM
NARRATIVE
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On 03/072023 Licensing Program Analysts (LPA) Anita Tristan and (LPA) Priscilla Zamudio conducted an unannounced case management inspection. LPA met with Eva Segura, Director for the purpose of conducting a case management inspection, regarding a lead exceedance referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at the facility. Fresno Regional Office received notification of water lead exceedance at the facility resulting from a recent water lead sampling test. Based on records reviewed from Child Care Center Lead Sampling and Reporting Tool and self-reported information to licensee #503603196 an outlet is impacted with an (ALE) of 6.1 ppb in the Room 1 License #503603196 in a Sink Faucet named outlet S (Far Left). This result indicates out of compliance over (ALE) 5.5 ppb. (See Plan of correction for further corrective action 809D).

Outlet has temporarily been made inoperable and has been replaced. Director agrees to continue with the resampling process for an action level result of under 5.5 ppb for compliance with a Certified Sampler. Director stated children are provided water from another sink that has been tested and is in compliance and they also bring their own water in water bottles. Facility will post results for parents to review Per PIN 21-21-1 CCP WD 101703 (b). In addition, parents and guardians will be notified by letter and verbally of the (ALE) Per PIN 21-21-1 CCP WD 101704 (b)(3).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, A type B deficiency is being cited: (see next page, 809 D). Director was 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: Cynthia BrannonTELEPHONE: (559) 650-7884
LICENSING EVALUATOR NAME: Anita TristanTELEPHONE: (559) 243-4588
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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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Document Has Been Signed on 03/07/2023 11:22 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: MONTESSORI SCHOOL OF MODESTO
FACILITY NUMBER: 503603196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2023
Section Cited

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(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. Testing results with fractional ppb
readings of less than 0.5 ppb shall be rounded down 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. (2) Licensees shall maintain a lead value at or below the
Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. (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.
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Director agrees to sumbit evidence of
remediation on outlet S in the infanct classroom testing at or below Action Level by POC due date 04/07/23. Director agrees to notify parents and guardians and posted (ALE) results at a reasonable location for Authorized Representatives to review as soon as possible.
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This requirement was not met evidence by: Based on record review provided by licensee indicating (ALE) of 6.1 ppb in Room 1 sink faucet named outlet S (far left). These results indicate out of compliance over (ALE) 5.5 ppb, which poses a potential health, safety or personal rights 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: Cynthia BrannonTELEPHONE: (559) 650-7884
LICENSING EVALUATOR NAME: Anita TristanTELEPHONE: (559) 243-4588
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
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