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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616736
Report Date: 04/21/2023
Date Signed: 04/21/2023 09:51:48 AM

Document Has Been Signed on 04/21/2023 09:51 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:CALVARY CHRISTIAN PRESCHOOLFACILITY NUMBER:
343616736
ADMINISTRATOR:ARRIAGA, SUSANFACILITY TYPE:
850
ADDRESS:4911 47TH AVENUETELEPHONE:
(916) 393-3633
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 0DATE:
04/21/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sue ArriagaTIME COMPLETED:
10:15 AM
NARRATIVE
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On April 21, 2023, Licensing Program Analyst (LPA) Amanda Sutter met with Director Sue Arriaga Assistant Director Hope Caramena for an unannounced Case Management Inspection. LPA observed care and observation of 19 children by three staff.

The purpose of today’s inspection was to follow up regarding water sampling that indicated Action Level Exceedance (ALE) for a drinking fountain that was tested for lead levels on 1/14/2023. On 1/30/2023 the facility was notified that water levels were in exceedance of 5 parts per billion in the drinking fountain that was tested. Since notification, the facility has made the drinking fountain inoperable by disconnecting the pipe from the water source.

The drinking fountain tested is in the outdoor play area for the preschool. Assistant Director stated that children bring out their own water bottles to the play area, or they are provided water through use of a pitcher and cups. Assistant Director stated that the facility did not initially plan to test the drinking fountain because it had not been in use, but were told the fountain needed to be tested by the tester. LPA asked if the facility had gone through the appropriate procedures to flush the tap beforehand and the Assistant Director stated that she did not believe that they did.

LPA informed Site Supervisor that Grant funding for testing and remediation is available referenced from Provider Information Notice (PIN) 21-04-CCP.

LPA reviewed this report with the Director and conducted an exit interview. One type B citation has been issued. A Notice of Site Visit was provided and should remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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 04/21/2023 09:51 AM - It Cannot Be Edited


Created By: Amanda Sutter On 04/21/2023 at 09:33 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: CALVARY CHRISTIAN PRESCHOOL
FACILITY NUMBER: 343616736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers (b) (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This regulation was not met as evidenced by:
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LPA observed fountain to be disconnected and the drinking fountain to be inoperable.
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Based on record review, the licensee did not comply with the section cited above, 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 Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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