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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340319280
Report Date: 03/30/2023
Date Signed: 03/30/2023 10:01:41 AM

Document Has Been Signed on 03/30/2023 10:01 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:FLORENCE MARKOFER ELEMENTARY SCHOOLFACILITY NUMBER:
340319280
ADMINISTRATOR:GORDON BLACKWOODFACILITY TYPE:
850
ADDRESS:9759 TRALEE WAYTELEPHONE:
(916) 686-5042
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 20DATE:
03/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariana RojasTIME COMPLETED:
10:20 AM
NARRATIVE
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On 03/30/2023, Licensing Program Analysts (LPAs) Erwin Tjhia and Gagandeep Singh met with facilitty representative, Mariana Rojas , for a Case Management inspection. The purpose of the inspection was to follow-up on a lead testing report dated 03/16/2023 which tested the water used for both consumption and hand washing in the facility. LPAs toured the facility and 3 staff members were supervising 20 children.

LPA was notified of the lead testing report on 03/16/2022 via email. The report revealed that two water outlets had elevated levels of lead. Facility representative, Mariana Rojas stated that the drinking fountain (Sample A) was inaccessible for use by have it covered. The facility has installed a dispenser as drinking water. Furthermore, the facility representative stated that the water outlet (Sample B) was never been used for cooking or drinking.

As a result of the water testing positive for lead, a deficiency was cited on subsequent page 809D. An exit interview was conducted and the report was reviewed with Facility repesentative, Mariana Rojas. Licensee Appeal Rights were provided. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 03/30/2023 10:01 AM - It Cannot Be Edited


Created By: Erwin Tjhia On 03/30/2023 at 09:42 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: FLORENCE MARKOFER ELEMENTARY SCHOOL
FACILITY NUMBER: 340319280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited

101700.3(b)(1)

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Lead Testing (b)(1) A result which values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
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The facility has blocked the faucet with the exceedance and is inaccessible.
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The water report dated 03/30/2023 revealed that the facility had elevated levels of lead in two water fountain. This is a potential health and safety risk to the children 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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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