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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503808081
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:01:05 PM


Document Has Been Signed on 02/22/2023 02:01 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:GRACE LUTHERAN SCHOOL - EXTENDED SCHOOL CAREFACILITY NUMBER:
503808081
ADMINISTRATOR:VIGARS, JEFFFACILITY TYPE:
840
ADDRESS:617 W. ORANGEBURG AVENUETELEPHONE:
(209) 529-1800
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:50CENSUS: 0DATE:
02/22/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Cindy O'HalloranTIME COMPLETED:
02:10 PM
NARRATIVE
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On 02/22/2023 Licensing Program Analyst (LPA) Jeovanna Yanez conducted an unannounced case management inspection. LPA met with Business Administrator, Cindy O'Halloran, who accompanied LPA on a tour of the facility. The purpose of today’s inspection is to address a lead exceedance referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) from water at the facility.

Fresno Regional Office (FRO) received notification that the facility has a high lead exceedance from a water lead sampling test collected on 1/16/2023. Based on records reviewed from the Child Care Center Lead Sampling and Reporting Tool, the following three outlets were affected: Outlet X shows an ALE of 69 ppb, Outlet Z shows an ALE of 9.7 ppb, Outlet W showed an ALE of 29 pbb. Based on LPA's observation, the facility has made the affected outlets inoperable, and is in the planning stages of repairing all affected outlets with a Certified Sampler. Licensee has agreed to post results on the parent board for review per PIN 21-21.1-CCP Written Directives (WD) 101703(b). In addition, parents and guardians will be notified of the ALE via letter, Per PIN 21-21.1-CCP WD 101704 (b)(3). Licensee submitted the following documents to FRO: Facility Sketch (LIC 999) for both indoor and outdoor areas, Child Care Center Sampling Checklist form (LIC 9276), External Water Sampler Self-Certification Form (LIC 9275). During the inspection, LPA obtained a copy of the lead testing report conducted by Enthalpy Analytical. The facility has agreed to continue with the re-sampling process for an action level result of under 5.5 ppb for compliance on all affected outlets.


Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D). Licensee was provided a copy of appeal rights. An exit interview was conducted with the Business Administrator.

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: Rene MancinasTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jeovanna YanezTELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 02/22/2023 02:01 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: GRACE LUTHERAN SCHOOL - EXTENDED SCHOOL CARE
FACILITY NUMBER: 503808081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
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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Licensee ceased operation of the affected outlets. Licensee agrees to submit documentation of replacement and remediation on all affected outlets. Updated plan of operation with changes to the facility will be submitted. Licensee will notify parents/authorized representatives of ALE
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This requirement was not met as evidenced by: Based on record review, the facility had an ALE of 10 ppb in Outlet A, which poses a potential health, safety or personal rights risk to persons in care.
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and corrective action being taken. Licensee will post results on parent board. Licensee will schedule to permanently remove the outlet. All required documentation to be submitted to CCL by POC Due Date.

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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: Rene MancinasTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jeovanna YanezTELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2