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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340314892
Report Date: 06/04/2024
Date Signed: 06/04/2024 08:52:54 AM


Document Has Been Signed on 06/04/2024 08:52 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GENERAL DAVIE, JR. PRIMARY CENTERFACILITY NUMBER:
340314892
ADMINISTRATOR:LEWIS, TIFFANYFACILITY TYPE:
850
ADDRESS:1500 DOM WAYTELEPHONE:
(916) 971-7375
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:296CENSUS: 67DATE:
06/04/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Laci LaneTIME COMPLETED:
09:15 AM
NARRATIVE
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On June 4th, 2024, at approximately 8:00 AM Licensing Program Analyst (LPA) Mandie Goodwin met with Facility Representative Laci Lane to conduct an unannounced case management inspection. During todays inspection there were 67 children supervised by 22 staff across 8 rooms. The purpose of today's inspection was to create a plan of correction following reports of lead exceedance in one of the facility outlets.

On April 18, 2024, the facility re-tested their water samples for lead. One water outlet sampled still indicated an Action Level Exceedance (ALE). This outlet is marked (PP) on the lead sample results and indicates a sink located in room 20. Water tested at 7.1 parts per billion (ppb), which exceeds the value of 5.5ppb. All other previous outlets that had tested for lead have been cleared.

Signs have been placed on the outlet in exceedance stating that the outlets should not be used for drinking or food preparation. Program Secretary stated that a work order is placed for the angle stops and supply lines to be changed and then the water will be retested. LPA received the lead testing map and other required documents (LIC 9275 External Water Sampler Self-Certification Form and LIC 9276 Child Care Center Sampling Checklist Form). LPA verified the room 20 is not currently in use by children.

A deficiency is cited on the following LIC809-D and the plan of correction was reviewed with Facility Representative, Laci Lane . A copy of this report and appeal rights were provided. Notice of Site visit was provided and should remain posted for 30 days.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Mandie GoodwinTELEPHONE: (916) 639-2867
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
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 06/04/2024 08:52 AM - 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GENERAL DAVIE, JR. PRIMARY CENTER
FACILITY NUMBER: 340314892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited

101700.3(b)(1)

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California Lead Action Level at Child Care Centers (b) Testing results with ... (1) A ... values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidenced by:
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Usage of the faucet was stopped immediately upon receiving the results. Facility Representative stated the faucet is awaiting a work order to replace parts. Alternate water is available from other sources that have not tested in exceedance.
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Based on record review, one water outlet tested exceeded the allowed 5.5 ppb, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Mandie GoodwinTELEPHONE: (916) 639-2867
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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