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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500316980
Report Date: 07/13/2022
Date Signed: 07/13/2022 02:54:25 PM

Document Has Been Signed on 07/13/2022 02:54 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:TUOLUMNE HEAD STARTFACILITY NUMBER:
500316980
ADMINISTRATOR:NUNES, HEIDIFACILITY TYPE:
850
ADDRESS:707 HERNDON RDTELEPHONE:
2095748442
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 0DATE:
07/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Aaron Castro TIME COMPLETED:
02:54 PM
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On 07/13/22 Licensing Program Analyst (LPA) Araceli Gibson conducted an unannounced case management inspection. LPA met with Aaron Castro, Supervisor of Environmental Health and Safety. Purpose of today's inspection is to conduct a case management inspection regarding a water lead exceedance referred to as Action Level Exceedance (ALE) of over 5 parts per billion (ppb) in the drinking water at the Tuolumne Elementary Preschool facility.

Fresno Regional Office received notification on 05/23/22 of Action Level Exceedance (ALE) at the facility resulting from a recent water lead sampling test. Based on findings from Forensic Analytical Consulting Services reported outlet G in classroom 29 was impacted as it is used for consumption. On May 18, 2022 authorized representatives were notified of the Action Level Exceedance at the facility. Classroom 29 is a partial day program with two session and will start the school year on 08/9/22. Currently there are no children enrolled or utilizing the classroom 29. LPA consulted with Aaron Castro and confirmed the facility has begun the 101705 Follow up Corrective Action Water Sampling process (i.e. replacement of the fixture was observed and documented flushing schedule was obtained), therefore LPA Gibson is requesting Child Care Center Sampling Checklist LIC 9276 be completed by staff and a certified External Water Sampler along with evidence of fixture testing under 5 parts per billion (ppb). (See Plan of correction for further corrective action 809D).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, A type B deficiency is being cited: (see next page, 809 D). Aaron Castro was provided a copy of appeal rights. An exit interview was conducted with Aaron Castro, Supervisor of Environmental Health and Safety

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Araceli Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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 07/13/2022 02:54 PM - It Cannot Be Edited


Created By: Araceli Gibson On 07/13/2022 at 01:56 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: TUOLUMNE HEAD START
FACILITY NUMBER: 500316980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
101238(a)

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101238(a) Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement was not met as evidence by:
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 Aaron Castro, Supervisor Enviironmental Health and Safety, agrees to submit a copy of the Child Care Center Sampling Checklist LIC 9276 to be completed by staff and a certified External Water Sampler along with evidence of the fixture testing under 5 parts per billion (ppb) to CCLD by POC date of 9/15/22.
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Based on LPA observation and records reviewed for classroom 29 outlet G found to be testing at Action Level Exceedence over 5 parts per billion (ppb) .
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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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Araceli Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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