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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700277
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:08:50 PM

Document Has Been Signed on 09/08/2023 01:08 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:LEMON GROVE SCHOOL DISTRICT - GOLDEN AVE PRESCHOOLFACILITY NUMBER:
376700277
ADMINISTRATOR:RICK OSERFACILITY TYPE:
850
ADDRESS:7885 GOLDEN AVENUETELEPHONE:
(619) 825-5637
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 6DATE:
09/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Melvetta OwensTIME COMPLETED:
01:15 PM
NARRATIVE
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On 09/8/2023 at 11:55 AM, Dana Stevens made an unannounced CASE MANAGEMENT inspection, for reported Lead Exceedance. LPA met with Director Melvetta Owens. LPA interviewed director and examined the water source (spigot) deemed at Action Level Exceedance.

Spigot reported with 5.5 ppb or greater lead exceedance levels are as follows:

Faucet located in Cafeteria sink (used for food preparation) spigot F 22.5 ppb

Director stated that spigot was replaced in 06/2021 during summer break when children were not present. Director stated district is currently processing the contract for vendor to perform re-testing within 30 days. LPA observed Spigot is covered and labeled not for use. Cafeteria staff have been informed not to use spigot in exceedance for any reason. All spigots inside the classroom were tested and found not in exceedance.

See LIC809D for Type B deficiency cited.

Exit interview conducted. Appeal rights were discussed and given to director on this date. Notice of Site Visit was given to director and must be posted for 30 days.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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Document Has Been Signed on 09/08/2023 01:08 PM - It Cannot Be Edited


Created By: Dana Stevens On 09/08/2023 at 12:45 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: LEMON GROVE SCHOOL DISTRICT - GOLDEN AVE PRESCHOOL
FACILITY NUMBER: 376700277

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) Written Directives: A result with 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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Spigot has been replaced and is not in use. A second testing will be completed within 30 days and Director will provide LPA with the results.
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Based on water testing results and interview, facility tested over the Action Level Exceedance level at one water outlet (spigots). This may pose a health, safety or personal rights risk to 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:Cynthia Gray
LICENSING EVALUATOR NAME:Dana Stevens
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
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