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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340319282
Report Date: 02/06/2024
Date Signed: 02/06/2024 10:04:45 AM

Document Has Been Signed on 02/06/2024 10:04 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:PASADENA STATE PRESCHOOLFACILITY NUMBER:
340319282
ADMINISTRATOR:BAGELMANN, LINDAFACILITY TYPE:
850
ADDRESS:4330 PASADENA AVENUETELEPHONE:
(916) 575-2374
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 18DATE:
02/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Linda BagelmannTIME COMPLETED:
10:20 AM
NARRATIVE
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On February 6, 2024, at approximately 9:15am Licensing Program Analyst (LPA) Kyrsten Williams met with
facility representative, Linda Bagelmann, for the purpose of an unannounced case management - lead testing/exceedance inspection. LPA observed a census of 18 children being supervised by 3 staff.

During today’s inspection, LPA followed up regarding water sampling that indicated an Action Level
Exceedance (ALE) for an Outdoor Water Drinking Fountain that was tested for lead levels. The facility had the water tested for lead on December 12, 2023. Based on the report, the Outdoor Drinking Fountain G was in lead level exceedance greater than 5.5 ppb. The fountain tested at 7.3 ppb. LPA observed the faucet and took photo documentation.

LPA and facility representative discussed corrective action. LPA confirmed that Drinking Fountain G will not be in use until corrected. The facility has uncontaminated drinking water readily available for children both indoors and outdoors using the indoor drinking fountain. Facility representative can view Lead Testing and Prevention information at https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information.

A deficiency is cited on the subsequent pages of this report. Appeal rights were provided. An exit interview
was conducted and this report was reviewed with the facility representative, Linda Bagelmann. A Notice of Site Visit was provided and shall remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/06/2024 10:04 AM - It Cannot Be Edited


Created By: Kyrsten Williams On 02/06/2024 at 09:43 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PASADENA STATE PRESCHOOL
FACILITY NUMBER: 340319282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2024
Section Cited

101700.3(b)(1)

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California Lead Action Level at Child Care
Centers b) Testing results with fractional ppb readings of 0.5 or greater shall be rounded up 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. This requirement was not
met, as evidenced by:
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The facility has since stopped using the water that was designated exceeding lead levels and shut the water off to the faucet. The facility has a work order to correct the faucets that will be sent to the LPA.
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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 outlets, which poses 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 Luca
LICENSING EVALUATOR NAME:Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024


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