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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500446
Report Date: 04/11/2023
Date Signed: 04/11/2023 02:19:04 PM

Document Has Been Signed on 04/11/2023 02:19 PM - 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:FORTUNE PRESCHOOLFACILITY NUMBER:
344500446
ADMINISTRATOR:MICHELLE ROYFACILITY TYPE:
850
ADDRESS:9424 BIG HORN BOULEVARDTELEPHONE:
(916) 793-3671
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 84TOTAL ENROLLED CHILDREN: 84CENSUS: 0DATE:
04/11/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michelle RoyTIME COMPLETED:
02:30 PM
NARRATIVE
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On 04/11/2023, Licensing Program Analyst Katy Maestas (LPA) conducted a field visit to the facility for the purpose of a case management inspection. LPA arrived at the facility and was met by Director Michelle Roy (D1). LPA disclosed the purpose of the inspection and was granted entrance into the facility. LPA toured the Preschool and observed 0 children in attendance. LPA determined, through accessing Guardian, that all required staff members were background cleared.

LPA followed-up on a lead testing report dated 03/27/2023 which tested the water used for consumption. The Department was notified of the testing on 04/04/2023. It was determined that one faucet in the kitchen tested for elevated levels of lead. LPA observed the faucet in the kitchen blocked off and marked as closed and inaccessible for use. The facility is using bottled water for drinking, food arrives prepackaged, and the teacher's bathroom is available for hand washing. D1 stated that the intent is to repair or replace the faucet and to have it re-tested.

As a result of the water testing for elevated levels of lead, a deficiency was cited on subsequent 809-D page. An exit interview was conducted and the report was reviewed with D1. LPA provided Licensee Appeal Rights to D1. 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: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 04/11/2023 02:19 PM - It Cannot Be Edited


Created By: Nola Maestas On 04/11/2023 at 02:07 PM
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: FORTUNE PRESCHOOL
FACILITY NUMBER: 344500446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2023
Section Cited
CCR
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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D1 stated that the faucet will be remediated or replaced and the water re-tested. D1 understands that the results of the re-testing must be emailed to LPA.

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The water report dated 03/27/2023 revealed that the facility had elevated levels of lead in one water faucet in the kitchen. 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:Jeanne Smith
LICENSING EVALUATOR NAME:Nola Maestas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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