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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623991
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:15:32 AM

Document Has Been Signed on 09/29/2022 10:15 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 DUDLEY HEAD STARTFACILITY NUMBER:
343623991
ADMINISTRATOR:BHAVNEET KAURFACILITY TYPE:
850
ADDRESS:8000 AZTEC WAYTELEPHONE:
(916) 263-3737
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 20TOTAL ENROLLED CHILDREN: 15CENSUS: 12DATE:
09/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Carmen Osorio-RuizTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analysts (LPA) Fabiola Diaz and Karyn Guerra met with Facility Representative Carmen Osorio-Ruiz. for an unannounced Case Management Inspection. LPA observed there were currently 12 children in care with 3 staff.

The purpose of today’s inspection was to follow up regarding water sampling that indicated Action Level Exceedance (ALE) for a faucet that was tested for lead levels on August 2022. Licensing was notified of the water levels that were in exceedance of 5 parts per billion in the faucet in the classroom which was used for drinking water. Carmen stated that the faucet was retested on 9/22/22, but Carmen has not received the test results

LPAs observed a water dispenser in the classroom. Carmen stated that the facility has been using the water dispenser for drinking water, and they fill a water jug to take outside with disposable cups. Carmen explained that the faucet has now only been used for washing hands.

LPAs informed the Facility Representative that Grant funding for testing and remediation is available referenced from Provider Information Notice (PIN) 21-04-CCP.

See LIC809-D for Type B deficiency. LPA reviewed this report with the Facility Representative and conducted an exit interview. A Notice of Site Visit was provided and should remain posted for 30 days.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
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 10:15 AM - It Cannot Be Edited


Created By: Fabiola Diaz On 09/29/2022 at 09:50 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 DUDLEY HEAD START
FACILITY NUMBER: 343623991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2022
Section Cited

101700.3(b)(1)

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101700.3 California Lead Action Level at Child Care Centers (b) Testing results with ... (1) A ... values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidenced by:
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LPAs observed a water dispenser in the classroom. Carmen stated that the facility has been using the water dispenser for drinking water, and they fill a water jug to take outside.
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Based on record review and interview, the faucet in the classroom exceeded the 5.5 ppb, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Carmen explained that the faucet has now only been used for washing hands. The faucet will not be used for water consumption, until it is no longer in lead levels exceedance.

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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:Roxana Saravia
LICENSING EVALUATOR NAME:Fabiola Diaz
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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