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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318128
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:36:47 PM

Document Has Been Signed on 09/19/2023 02:36 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FLORIN ELEMENTARY SCHOOLFACILITY NUMBER:
340318128
ADMINISTRATOR:PASLEY, ROBERTFACILITY TYPE:
850
ADDRESS:7300 KARA DRIVETELEPHONE:
(916) 383-0530
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 28DATE:
09/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Wilbert VallartaTIME COMPLETED:
02:45 PM
NARRATIVE
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On September 19th, 2023 Licensing Program Analyst (LPA) Mandie Goodwin met with Principal Wilbert Vallarta to conduct an unannounced case management inspection. During today's inspection there were 28 preschool children being supervised by 7 teachers across 2 classrooms. The purpose of today's inspection was to create a plan of correction following a report of lead exceedance in one of the facility outlets.

On 08/02/2023, the facility tested water samples for lead. One water outlet sampled indicated an Action Level Exceedance (ALE). This outlet is marked F on the facility sketch provided by the center. Outlet F was previously tested on 3/07/2023 and was labeled E. This outlet correlates to a drinking fountain located inside the A-1 classroom. Outlet previously tested at 5.9 ppb and was retested at 11.0 ppb. The facility was notified that water lead levels were in exceedance of 5 parts per billion in outlet F, and that corrective actions are being taken.

During today’s inspection, Principal informed LPA that outlet F has not been used by children since initial notification of lead exceedance. LPA observed that the classroom has a water jug delivery service to provide drinking water. A plan of correction is being issued to ensure that outlet F is made inoperable, removed, and/or replaced. All other faucets used by preschool children have been tested and are not in Action Level Exceedance. Outlet F has been covered by a plastic bag, to make it inaccessible.

A deficiency is cited on the following LIC809-D and the plan of correction was reviewed with the Principal, Wilbert Vallarta. A copy of this report and appeal rights were provided to the Principal.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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 09/19/2023 02:36 PM - It Cannot Be Edited


Created By: Mandie Goodwin On 09/19/2023 at 02:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FLORIN ELEMENTARY SCHOOL
FACILITY NUMBER: 340318128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
HSC
101700.3(b)(1)

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101700.3 ...Lead Action Level... (b) ...(1) If testing indicates an Action Level Exceedance at any water outlet, the water... is deemed not safe to drink and an immediate response... shall be required.
This requirement was not met as evidenced by:
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Principal provided proof that the outlet has been made inaccessable and that alternate water source is available. Facility will continue to make corrections to bring lead results to under 5.5ppb or permenantly remove drinking fountain.
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Based on record review the facility did not comply with the above regulation as the lead action level was exceeded in one water outlet, which poses 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 Luca
LICENSING EVALUATOR NAME:Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


LIC809 (FAS) - (06/04)
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