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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243808137
Report Date: 01/31/2023
Date Signed: 01/31/2023 10:53:22 AM

Document Has Been Signed on 01/31/2023 10:53 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:DOS PALOS STATE PRESCHOOLFACILITY NUMBER:
243808137
ADMINISTRATOR:FRANCO, VIRGINIAFACILITY TYPE:
850
ADDRESS:1734 CALIFORNIA AVETELEPHONE:
(209) 392-0267
CITY:DOS PALOSSTATE: CAZIP CODE:
93620
CAPACITY: 67TOTAL ENROLLED CHILDREN: 114CENSUS: 21DATE:
01/31/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Priscilla GomezTIME COMPLETED:
11:00 AM
NARRATIVE
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On 01/31/2023 Licensing Program Analyst (LPA) Jeovanna Yanez conducted an unannounced case management inspection. LPA met with Director, Priscilla Gomez, who accompanied LPA on a tour of the facility. 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 (FRO) received notification that the facility has a high lead exceedance from a water lead sampling test collected on 1/11/23. Based on records reviewed from the Child Care Center Lead Sampling and Reporting Tool and self-reported information, Outlet A (ROOM 1 BUBBLER) shows an ALE of 13.9 ppb. Based on documentation submitted and LPA's observation, the facility has made the outlet inoperable, and has already submitted a work order to permanently remove the outlet with a Certified Sampler. The facility is providing alternative potable water via filtered water dispenser 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 per PIN 21-21.1-CCP Written Directives (WD) 101703(b). Licensee submitted the following documents to FRO: 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), and pictures of the outlets being tested. The facility has agreed to continue with permanently removing the outlet.

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 Priscilla Gomez.

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: Rene Mancinas
LICENSING EVALUATOR NAME: Jeovanna Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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 01/31/2023 10:53 AM - It Cannot Be Edited


Created By: Jeovanna Yanez On 01/31/2023 at 10:32 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: DOS PALOS STATE PRESCHOOL
FACILITY NUMBER: 243808137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited

101700.3

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(a) California’s Action Level for lead in water at Child Care Centers is 5 ppb.
(b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. Testing results with fractional ppb readings of less than 0.5 ppb shall be rounded down to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. (2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. (c) If testing indicates an Action Level Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response pursuant to section 101704 shall be required.
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Licensee has ceased operation of the affected water outlet and made the outlet inoperable. Licensee has notified parents/authorized representatives of ALE and corrective action being taken. Licensee has posted results on parent board. Licensee has placed a work order to permanently
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This requirement was not met as evidenced by: Based on record review, the facility had an ALE of 13.9 ppb in Outlet A, which poses a potential health, safety or personal rights risk to persons in care.
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remove the outlet. Updated plan of operation with changes to the facility will be submitted. 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:Rene Mancinas
LICENSING EVALUATOR NAME:Jeovanna Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023


LIC809 (FAS) - (06/04)
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