360911002-5-8-2023-09-CC-ASHA-CRMND5-20230508102145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360911002
Report Date: 05/08/2023
Date Signed: 05/08/2023 10:21:55 AM

Document Has Been Signed on 05/08/2023 10:21 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	FUSD/PALMETTO ELEMENTARY SCHOOL		FACILITY NUMBER:	360911002
ADMINISTRATOR:	DARCY WHITNEY		FACILITY TYPE:	850
ADDRESS:	9325 PALMETTO AVENUE		TELEPHONE:	(909) 357-5710
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 48	CENSUS: 33	DATE:	05/08/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Laura Bliss- Lead Teacher		TIME COMPLETED:	10:35 AM

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Due to required lead testing requirements, Licensing Program Analyst (LPA), Aman Sharma conducted a Case Management inspection based on lead testing results received from the facility. LPA toured the facility, took census, and met with lead teacher, Laura Bliss to further discuss lead results received and measures taken for remediation of lead exceedances.

During the inspection, LPA toured and obtained photos of the following water outlets identified with lead exceedances: Outlet F (18 ppb) which was identified as an indoor faucet located in the back of classroom #2.

LPA observed and obtained photos of required signage posted at the outlets for cessation of use.

Facility implemented the following plan of action until formal remediation can be completed: Facility is utilizing their own water bottles brought from home, labeled with each child's name on them. LPA verified their functionality and observed adequate storage of 5 gallon water bottles. LPA was informed by facility maintenance staff that outlet F has been getting flushed in the morning as well as the evening. Outlets will then be re-tested for exceedances at a later date. The identified water outlets have been covered and sealed with posted signage for non-use.

Facility is currently in the process of repair of fixture F. Additionally, LPA observed notification of lead results posted at the facility entry.

Due to water outlet F testing above approved lead levels, a deficiency has been cited. See LIC809D for Type B Deficiency.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: FUSD/PALMETTO ELEMENTARY SCHOOL	FACILITY NUMBER: 360911002
	VISIT DATE: 05/08/2023

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Additionally, the following resources were discussed and provided from PIN 21-21.1- CCP dated December 28, 2022:
101700.6 Grant Funding for Qualifying Child care Centers

(a) Senate Bill 862, Chapter 449, Statutes of 2018 allocated $5 Million to the State Water Resources Control Board for testing and remediation of lead in the drinking water of Child Care Centers based on the following criteria:

(1) Those that serve children zero to five years of age, with the highest priority for Child Care Centers that provide care for children zero to three years of age.

(2) Those that have 50 percent or more of their registered children who receive subsidized care.

(3) Those that operate only one facility.

(b) To determine a Child Care Center’s eligibility for possible funding the Department will provide access to a link to an online eligibility form located on the Department’s website and on Sacramento State’s Office of Water Programs website.

(1) A Child Care Center interested in financial assistance shall complete the eligibility form, which shall include instructions for completing and returning it, prior to receiving any grant funding for which it may qualify. To determine a Child Care Center’s eligibility for possible funding, the provider will need to complete an online eligibility form available at Office of Water Programs’ website

An exit interview was conducted, and appeal rights discussed. LPA provided lead teacher, Laura Bliss with a copy of this report and notice of site visit. Notice of site visit must remain posted for the next 30 days.

This report must be made available to the public upon request for three years.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Aman Sharma
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/08/2023 10:21 AM - It Cannot Be Edited

Created By: Aman Sharma On 05/08/2023 at 10:09 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: FUSD/PALMETTO ELEMENTARY SCHOOL	FACILITY NUMBER: 360911002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/05/2023 Section Cited CCR 101700.3(b)(1)	1 2 3 4 5 6 7	California Lead Action Level at Child Care Centers 101700.3 (b)(1): A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will implement corrective action pursuant to section CCR 101704, for immediate cessation of outlets testing with action level exceedance until it is replaced, removed or retested pursuant to section CCR 101705.
	8 9 10 11 12 13 14	Based on records review of required lead testing, the facility had lead values of 5.5 or above on water outlet F (12ppb) This is a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	The facility agrees to return a result at or below the Acton level. Facility will notify CDSS with completion within 30 days.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Kimberly Williams

LICENSING EVALUATOR NAME:

Aman Sharma

LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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