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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911006
Report Date: 02/02/2023
Date Signed: 02/02/2023 09:53:48 AM

Document Has Been Signed on 02/02/2023 09:53 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/CYPRESS ELEMENTARY SCHOOLFACILITY NUMBER:
360911006
ADMINISTRATOR:DARCY WHITNEYFACILITY TYPE:
850
ADDRESS:9751 CYPRESSTELEPHONE:
(909) 357-5460
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 30DATE:
02/02/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gloria Quinonez/Lead TeacherTIME COMPLETED:
10:28 AM
NARRATIVE
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On 2/2/23 at 9:00 pm, Licensing Program Analyst (LPA), Patricia Berry conducted a Case Management inspection due to required lead testing requirements based on lead testing results received on the facility for outlet F level 8.6. LPA toured the facility, took census and met with Lead Teacher Gloria Quinonez 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 outlet (F) identified with lead exceedances: Outlet:( F) -8.6, was identified, LPA also observed two drinking faucets in classroom K3 and A8 covered with signage; not noted on the CDSS Water Testing list. LPA took photos of required signage for cessation of use.
Facility implemented the following plan of action until formal remediation can be completed on water outlet: (F): Covered water outlet, posted required signage for non-use and will complete repairs to the outlet affected. Outlet (F), is a drinking fountain on the playground, LPA also observed both drinking faucetsK-3 and A8 in the classrooms are covered. children are not using the outlets. Facility is in the process of repairs and retesting. LPA observed notification of lead results posted at the facility: Front door to classroom. Photos also obtained of additional source for access to water -include children bring there own water bottles and the facility provides water bottles as well.

Due to facility water outlet testing for lead exceedance level above approved lead levels, a deficiency has been cited. See LIC809D.


Additionally, the following resources were discussed and provided from PIN 21-21-CCP dated July 28, 2021: Exit interview conducted with lead teacher Gloria Quinonez, report, appeal rights and notice of site visit issued. Notice of site visit must be posted for 30 days in classrooms K3 and A8
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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 02/02/2023 09:53 AM - It Cannot Be Edited


Created By: Patricia Berry On 02/01/2023 at 11:43 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/CYPRESS ELEMENTARY SCHOOL
FACILITY NUMBER: 360911006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2023
Section Cited

101700.3(b(1)

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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:
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Facility will implement corrective action pursuant to section CCR 101704 for immediate cessation of outlet testing with action level exceedance until it is replaced and retested pursuant to section CCR 101705 and returns a result at or below the Acton level.
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Based on records review of required lead testing, the facility had lead values of 5.5 ppb or above on water outlet: (F) (8.6).
Also observed two drinking facutes in the classrooms covered K3 and A8.
This is a potential health and safety risk to persons in care.
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Facility will notify CDSS with completion by POC due date: 2/27/23.

Facility will complete repairs and comple re-flush process required for retesting.

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Patricia Berry
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
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