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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621652
Report Date: 03/01/2023
Date Signed: 03/01/2023 11:36:55 AM

Document Has Been Signed on 03/01/2023 11:36 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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:COUNTRY CLUB EARLY CARE & LEARNING CENTERFACILITY NUMBER:
393621652
ADMINISTRATOR:APRIL BETHARDSFACILITY TYPE:
850
ADDRESS:2448 COUNTRY CLUB BOULEVARDTELEPHONE:
(209) 941-9100
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 38DATE:
03/01/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Veronica GonzalezTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) David Nguyen and Lauren Scott met with director, Veronica Gonzalez for a Case Management inspection. The purpose of the inspection was to follow-up on a lead testing report, which tested the water in the facility for lead levels.

LPA was notified of the lead testing report on 12/14/2022 via email. The report revealed that one water outlet in room 2 had elevated levels of lead (6.5ppb). During today's inspection, LPA's observed that the fountain has been removed. LPA's observed a water pitcher and cups that are being used inside and outside for children to consume water.

As a result of the water testing positive for lead, a deficiency was cited on a subsequent page, LIC 809D. An exit interview was conducted and the report was reviewed with director, Veronica Gonzales. A Notice of Site 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.

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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 03/01/2023 11:36 AM - It Cannot Be Edited


Created By: David Nguyen On 03/01/2023 at 11:16 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: COUNTRY CLUB EARLY CARE & LEARNING CENTER
FACILITY NUMBER: 393621652

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2023
Section Cited

101700.3(b)(1)

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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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During today's visit LPAs observed that the affected water outlet was removed and Facility is providing water in a water pitcher with cups to children
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The water report revealed that the facility had elevated levels of lead in one water fountain in room 2 at 6.5ppb. 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:Chayntel Hunter
LICENSING EVALUATOR NAME:David Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
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