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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393601458
Report Date: 03/30/2023
Date Signed: 03/30/2023 11:53:52 AM


Document Has Been Signed on 03/30/2023 11:53 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:ADELITA MIGRANT CHILD DEVELOPMENT CENTERFACILITY NUMBER:
393601458
ADMINISTRATOR:RICO, ELIZABETHFACILITY TYPE:
850
ADDRESS:14320 EAST HARNEY LANETELEPHONE:
(209) 368-2087
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:50CENSUS: 0DATE:
03/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Elizabeth RicoTIME COMPLETED:
12:20 PM
NARRATIVE
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On 03/30/2023, Licensing Program Analysts (LPAs) Erwin Tjhia and Gagandeep Singh met with Director,Elizabeth Rico for a Case Management inspection. The purpose of the inspection was to follow up on a recent report of the lead testing in the facility of the water used for drinking and cooking. Present in the facility were 14 staff. There were no children present during today inspection

LPA was notified of the lead testing report on 12/29/2022 via email. The report revealed that 1 water outlets, Sample B had elevated levels of lead. Center Manager, Elizabeth Rico reported that the water line this water outlets have been fixed and replaced. The water outlet B will be retested on 04/05/2023 according to the written directives. Facility is using bottled water for dinking and any food preparation.

As a result of the water testing positive for elevated lead levels, a deficiency was cited on subsequent page 809D.



An exit interview was conducted and the report was reviewed with Center Manager, Elizabeth Rico. Licensee Appeal Rights were provided. 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
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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 03/30/2023 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: ADELITA MIGRANT CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 393601458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2023
Section Cited

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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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According to director, the water outlet B have been fixed and replaced. The water outlet B will be retested on 04/05/2023 according to the written directives
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Lead test result tested on 12/29/2022 had lead level exceeding 5 parts per billion in Outlets B, 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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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