<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125401062
Report Date: 06/09/2022
Date Signed: 06/09/2022 09:49:21 AM

Document Has Been Signed on 06/09/2022 09:49 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
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:HEAD START - FORTUNAFACILITY NUMBER:
125401062
ADMINISTRATOR:HOUSEWORTH, MELISSAFACILITY TYPE:
850
ADDRESS:2085 NEWBURG ROADTELEPHONE:
(707) 725-6532
CITY:FORTUNASTATE: CAZIP CODE:
95540
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 13DATE:
06/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Maria HerreraTIME COMPLETED:
09:49 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/9/22 at 8:59am, Licensing Program Analyst (LPA) Mendez made a case management inspection and met with Maria Herrera. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucets tested above the allowable level (5.5 ppb) of lead in the water:

Faucet “A” – kitchen sink, 8.9ppb
Faucet “J” – Class 1 drinking fountain indoors, 30ppb

The staff have made the faucet J inaccessible by tape over plastic cover. Faucet A has an attached Britta filter.The licensee plans to replace and retest the faucet. Children in care are receiving drinking water from water filter kitchen sink

The following deficiency is being cited (see LIC 809D). A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee facility representative Maria Herrera.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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 06/09/2022 09:49 AM - It Cannot Be Edited


Created By: Bianca Mendez On 06/09/2022 at 09:17 AM
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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: HEAD START - FORTUNA
FACILITY NUMBER: 125401062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/09/2022
Section Cited
CCR
101238(a)

1
2
3
4
5
6
7
The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
1
2
3
4
5
6
7
The licensee agrees to submit an LIC 9275 and LIC 9276 by 7/2/22. The licensee has made the faucets temporarily inaccessible by plastic cover with tape. The licensee plans to replace and retest the faucet . Retesting documents will be submitted within 2 weeks of the completed sampling.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on record review, the facility had 2 faucets that exceeded that allowable levels of lead in the water. This is a potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Megan Aviles
LICENSING EVALUATOR NAME:Bianca Mendez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2