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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153810191
Report Date: 01/19/2023
Date Signed: 01/19/2023 12:06:01 PM


Document Has Been Signed on 01/19/2023 12:06 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 SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:CAL IVY PREP AT CSUBFACILITY NUMBER:
153810191
ADMINISTRATOR:MILLER, AMYFACILITY TYPE:
830
ADDRESS:9001 STOCKDALE HWYTELEPHONE:
(661) 654-3165
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:18CENSUS: 10DATE:
01/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Amy Miller TIME COMPLETED:
12:20 PM
NARRATIVE
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On 01/19/23 Licensing Program Analyst (LPA) Daniel Alvarez conducted an unannounced case management inspection. LPA Alvarez met with Director Amy Miller who accompanied LPA on a tour of the facility, and a census was taken. The purpose of today's inspection is to address the lead exceedance, referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at the facility.
The Fresno South Regional Office received notification of water lead exceedance at the facility resulting from a water lead sampling test collected on 12/16/2022. Records were reviewed from A-Tech Consulting, Inc. and discussions with Director Miller, it has been determined that there is an exceedance to outlet (C) in the facility. LPA Alvarez inspected outlet (C) it was observed to be the kitchen sink for washing dishing that was impacted with 5.6ppb (ALE) of lead. Director Miller stated the facility has made outlet (C) inoperable to facility staff by placing an "Do Not Use" sign on the faucet. The faucet will not be used until the facility has received the results from a second water lead sampling test.

(See plan of correction for further corrective action 809D). Facility has already notified all the authorized representatives of this corrective action in English.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809D). Director Miller was provided a copy of the appeal rights. An exit interview was conducted with Director Miller.
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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Daniel Q AlvarezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 01/19/2023 12:06 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 SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: CAL IVY PREP AT CSUB
FACILITY NUMBER: 153810191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited

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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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Per Director affected outlet has since been replaced. Facility will conduct daily flushing for three weeks and will have a second water lead sampling test and notify Community Care Licensing (CCL) of results.
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Based on record review, one outlet at the facility contained 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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Facility will notify all parents/authorized representatives of any corrective action already taken at the facility. Director stated she will conduct a follow up water sample as outlined in Written Directives Section 101705 and submit all required documentation to CCL by 02/20/23.

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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: Susie FanningTELEPHONE: (559) 650-7890
LICENSING EVALUATOR NAME: Daniel Q AlvarezTELEPHONE: 559-243-4588
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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