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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 553601751
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:31:21 PM


Document Has Been Signed on 11/08/2022 12:31 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:AMADOR-TUOLUMNE COMMUNITY ACTION AGENCY HEAD STARTFACILITY NUMBER:
553601751
ADMINISTRATOR:TIFFANY DOBBSFACILITY TYPE:
850
ADDRESS:20300 SOULSBYVILLE ROADTELEPHONE:
(209) 533-3143
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:24CENSUS: 14DATE:
11/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tiffany DobbsTIME COMPLETED:
12:45 PM
NARRATIVE
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On 11/08/2022 at 11:00 AM, Licensing Program Analysts (LPAs) Tiffanie Diep and Elvira Sierra met with Director, Tiffany Dobbs, 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 5 staff present supervising 14 children.

The Regional Office was notified that the lead testing results indicated an Action Level Exceedance (ALE) for a drinking fountain (Outlet B) located in the classroom which was tested on 09/17/2022. On 10/20/2022, the facility was notified that water levels in Outlet B were in exceedance of 5.5 parts per billion (ppb). Director stated Outlet B has not been used since March 2020 in response to COVID-19. Director stated Outlet B was removed from the classroom and capped off. Director stated drinking water is obtained from the kitchen. LPAs verified the affected water outlet was removed and inoperable and observed alternative drinking water available at other outlets 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, Tiffany Dobbs. A notice of site visit was posted and must remain posted for 30 days.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tiffanie DiepTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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Document Has Been Signed on 11/08/2022 12:31 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: AMADOR-TUOLUMNE COMMUNITY ACTION AGENCY HEAD START
FACILITY NUMBER: 553601751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2022
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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Based on record review, the lead testing results indicated an Action Level Exceedance for a drinking fountain located in the classroom which was tested on 09/17/2022. This poses a potential health, safety, or personal rights risk to children in care.
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A written statement and documentation of faucet removal will be submitted to LPA by 12/08/2022.

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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tiffanie DiepTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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