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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623182
Report Date: 09/29/2022
Date Signed: 09/29/2022 09:29:13 AM

Document Has Been Signed on 09/29/2022 09:29 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:SETA BRET HARTE HEAD STARTFACILITY NUMBER:
343623182
ADMINISTRATOR:XAYAVONG, SAMANTHAFACILITY TYPE:
850
ADDRESS:2761 9TH AVENUETELEPHONE:
(916) 263-3800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 21DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Samantha XayavongTIME COMPLETED:
09:45 AM
NARRATIVE
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On September 29, 2022 at approximately 9:00 AM, Licensing Program Analyst (LPA) Alize Tillery, arrived to the facility to conduct a case management inspection. Upon arrival, there were 21 children, supervised by 5 staff.

On 7/1/2022, the program received their Lead Water Testing on water outlets that were being used for cooking or drinking water. The Lead Testing identified one water outlet that has a Lead Exceedance over the amount of 5.5ppb, testing at 8.900ppb. A test result showing an amount of 5.5ppb, or over, is considered an Lead Action Level Exceedance, that can represent a risk of permanent, lifelong brain damage.

Due to this being a potential risk, of becoming and immediate risk, or threat to the health, safety and/or personal rights to children in care, a type B deficiency is being cited on the following 809D page.

LPA reviewed the report with Director, reviewed and provided Appeal Rights and a Notice of Site Visit, which is to remain posted for 30 days.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 09/29/2022 09:29 AM - It Cannot Be Edited


Created By: Alize Tillery On 09/29/2022 at 09:16 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: SETA BRET HARTE HEAD START
FACILITY NUMBER: 343623182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited

101700.3(b)(1)

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(b)(1) A result with calues of 5.5 ppb or greater shall be deemed an Action Level Exceedance

This requirment was not met, based on results received that showed water outlet D with a lead exceedance of 8.900 ppb.
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Director stated that the water fountatin has since been capped off, shutting off the water drinking fountain in the toddler classroom. Director showed LPA that the water fountain does not work.
Director stated they will use the preschool side water source.
LPA will clear the deficiency effective today.

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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:Alize Tillery
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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