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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405628
Report Date: 12/18/2023
Date Signed: 12/18/2023 01:57:55 PM

Document Has Been Signed on 12/18/2023 01:57 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVSACCA - KIDS COUNTRY AT QUAIL RUNFACILITY NUMBER:
073405628
ADMINISTRATOR:TRUONG, JONATHANFACILITY TYPE:
840
ADDRESS:4040 GOLDEN BAY AVE.TELEPHONE:
(925) 552-4488
CITY:SAN RAMONSTATE: CAZIP CODE:
94582
CAPACITY: 174TOTAL ENROLLED CHILDREN: 99CENSUS: 22DATE:
12/18/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Jonathan TruongTIME COMPLETED:
01:54 PM
NARRATIVE
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On 12/18/2023 at 1:28pm, Licensing Program Analyst (LPA) Morgan Pringle conducted a case management inspection due to the center's lead testing results. The facility is on the Quail Run Elementary School campus. LPA met with Director Jonathan Truong. There were twenty-two (22) children and seven (7) additional staff members present during LPA's visit.

The department was notified that one (1) water outlet tested on 11/5/2022 located in room two (2) had elevated lead levels that had exceeded 5.5 ppb. This exceeded the Action Level Exceedance (ALE) established by the state for lead exposure.

The outlet was immediately closed off and made inaccessible to the children in care. San Ramon Unified School District replaced the outlet and it was retested on 1/28/2023. The new outlet tested below 5.5 ppb.

See LIC809D for Type B deficiency cited during today's inspection.

Exit interview conducted with Director Jonathan Truong.

A notice of site visit was provided and must be posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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 12/18/2023 01:57 PM - It Cannot Be Edited


Created By: Morgan Pringle On 12/18/2023 at 01:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVSACCA - KIDS COUNTRY AT QUAIL RUN
FACILITY NUMBER: 073405628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) - Lead Testing Written Directive - A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance (ALE)
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The outlet in Room 2 that had exceeded lead levels was replaced and was retested on 1/28/2023. The new faucet tested at a level below the maxium level of 5.5 ppb. No Plan of Correction needed.
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This requirement is not met as evidenced by: Based on record review, the facility had 1 outlet in Room 2 that had an ALE of 5.5ppb or greater which posed a potential health and safety risk to 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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


LIC809 (FAS) - (06/04)
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