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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393612197
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:20:28 PM

Document Has Been Signed on 05/12/2023 12:20 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:LINCOLN ELEMENTARY PRESCHOOLFACILITY NUMBER:
393612197
ADMINISTRATOR:MICHELLE DENNERTFACILITY TYPE:
850
ADDRESS:6910 GETTYSBURG PLACETELEPHONE:
(209) 953-8651
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 24TOTAL ENROLLED CHILDREN: 48CENSUS: 17DATE:
05/12/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Rena DameleTIME COMPLETED:
11:00 AM
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On 05/12/23, Licensing Program Analyst (LPA) Elvira Sierra met with facility representative, Rena Damele for an unannounced Case Management Inspection. LPA observed 17 children being care for by 3 staff members.
The purpose of today’s inspection was to follow up regarding a water sampling that indicated an Action Level Exceedance (ALE) for a drinking fountain in classroom # 50 that was tested for lead levels on 04/17/23. On 05/01/23 the facility was notified that water levels were in exceedance of 5 parts per billion in the adult drinking fountain (drinking fountain #A) that was tested. Since receiving the notification, the water fountain was shut down and taken out of service. Notices were posted indicating the outlet is not allowed for use. Alternative drinking water is available at other outlets within the facility. Facility representative stated that facility also provide water bottles. if needed. Per facility representative all children fountains were not affected and they are cleared. The adult drinking faucet that was affected will not be replaced and has been removed.

Facility representative stated that the line of the affected faucet will be retested in 20 days and the results will be send to Licensing. LPA informed facility representative that Grant funding for testing and remediation is available referenced from Provider Information Notice (PIN) 21-04-CCP.

A Type B deficiency was cited on the subsequent page (LIC809-D) of this report. An Exit interview conducted, and the report was reviewed and provided to Facility Representative, Rena Damele. LPA posted the Notice of Site Visit and Facility Representative acknowledges it must remain posted for 30 days. A Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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 05/12/2023 12:20 PM - It Cannot Be Edited


Created By: Elvira Sierra On 05/12/2023 at 11:14 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: LINCOLN ELEMENTARY PRESCHOOL
FACILITY NUMBER: 393612197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2023
Section Cited
CCR
101700.3(c)

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101700.3 California Lead Action Level at Child Care Centers (c) If testing indicates an...Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response...shall be required. This requirement was not as evidenced by:
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LPA observed that outlet A has been permanently ceased and removed. Facility representative advised that outlet A has not been used since 05/01/23.
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Lead test results tested on 04/17/23, showed outlet A in the facility with lead levels exceeding 5 parts per billion (ppb). This poses a potential risk to the health and safety of 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 Engelman
LICENSING EVALUATOR NAME:Elvira Sierra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
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