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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310306371
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:12:02 PM

Document Has Been Signed on 05/17/2022 01:12 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KIDZCOMMUNITY - CLIPPER GAP HEAD START (PS)FACILITY NUMBER:
310306371
ADMINISTRATOR:RAMEY FAHRNEYFACILITY TYPE:
850
ADDRESS:15820 APPLEGATE ROADTELEPHONE:
(530) 878-1600
CITY:CLIPPER GAPSTATE: CAZIP CODE:
95603
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 11DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Tania SierraTIME COMPLETED:
01:25 PM
NARRATIVE
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On Tuesday, May 17, 2022 at 12:25 pm LPAs Lea Habtom and Jeremey McClain arrived at KidzCommunity- Clipper Gap Head Start (PS) for an unannounced case management visit. There were 11 preschool children being supervised by 3 staff. All staff present during today's visit have fingerprint clearance. LPAs met with lead teacher Tania Sierra to address the lead level results in exceedance of 5 parts per billion for the sink that was tested in the kitchen. Water samples were taken on April 21, 2022 which showed a result of 7.8 parts per billion. Lead teacher, Tania, stated prior to receiving the results the faucets was never in use for consumption and food preparation due to the water coming from a well. Tania states since operating they've used filtered water from a water cooler to wash food and for children to drink from. Tania states water is delivered to the facility and that the county visits the facility once a month to treat the water supply. During today's visit, Tania agreed to continue to use the alternate water source, the cooler, for food preparation and consumption. Tania is aware that the faucet at the facility is only to be used to wash hands.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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 05/17/2022 01:12 PM - It Cannot Be Edited


Created By: Lea Habtom On 05/17/2022 at 12:57 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: KIDZCOMMUNITY - CLIPPER GAP HEAD START (PS)
FACILITY NUMBER: 310306371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2022
Section Cited
CCR
101238(a)

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Physical, Plant, Building & Grounds: 101238(a):
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.

This requirement was not met as evidenced by:
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Lead teacher, Tania, agreed to continue to use the alternate water supply from the water cooler to wash food and for consumption.
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Lead results of 7.8 parts per billion were in excedance of the standard level considered safe of 5 parts per billion,
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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:Keven Peters
LICENSING EVALUATOR NAME:Lea Habtom
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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