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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103808802
Report Date: 11/15/2022
Date Signed: 11/16/2022 08:26:44 AM

Document Has Been Signed on 11/16/2022 08:26 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:FUSD-HAMILTONFACILITY NUMBER:
103808802
ADMINISTRATOR:MATHIES, DEANNAFACILITY TYPE:
850
ADDRESS:102 E. CLINTONTELEPHONE:
(559) 457-3690
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 24TOTAL ENROLLED CHILDREN: 33CENSUS: 0DATE:
11/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Debbie JohnsonTIME COMPLETED:
03:45 PM
NARRATIVE
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On 11/15/2022 Licensing Program Analyst (LPA) Jeovanna Yanez conducted an unannounced case management inspection. LPA met with Lead Teacher, Debbie Johnson who accompanied LPA on a tour of the facility. No children were present during the inspection. 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 received notification that the facility has a high lead exceedance from a water lead sampling test collected on 10/28/22. Based on records reviewed from the CA Water Board Data Management System, and self-reported information from the facility, the water fountain in the classroom (outlet A) had a result of 6.34 ppb. Based on the incident report submitted and LPA's observation, the facility has made the outlet inoperable, and is in the planning stages of repairing the outlet with a Certified Sampler. The facility is providing alternative potable water via purified bottled water to children, visitors, and staff during hours of operation. Parents/authorized representatives have been notified of the ALE and any corrective action being taken, and results of the lead testing results have been posted on the parent board. Licensee submitted the following documents along with the incident report: 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), Lead testing results for the facility, from LA Testing, Pictures of faucets/fountains being tested. Facility. The facility has agreed to continue with the re-sampling process for an action level result of under 5.5 ppb for compliance.


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 Lead Teacher.

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.

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Jeovanna Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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 11/16/2022 08:26 AM - It Cannot Be Edited


Created By: Jeovanna Yanez On 11/15/2022 at 03:17 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: FUSD-HAMILTON
FACILITY NUMBER: 103808802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2022
Section Cited

101700.3(b)(1)

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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 ... (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance (ALE). This requirement was not met as evidenced by:
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Facility has ceased operation of the affected water outlet and made the outlet inoperable. Updated plan of operation with changes to the facility has already been submitted. Facility has already notified parents/authorized representatives of corrective action already taken. Facility will repair and replace the
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Based on record review and observation, one outlet at the facility contained high lead exceedance greater than 5.5 ppb. This poses a potential health, safety or personal rights risk to persons in care.
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affected outlet and conduct follow up water sample as outlined in Written Directives Section 101705. 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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Jeovanna Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022


LIC809 (FAS) - (06/04)
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