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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570310219
Report Date: 10/27/2022
Date Signed: 10/27/2022 10:16:49 AM

Document Has Been Signed on 10/27/2022 10:16 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:DAVIS PARENT NURSERY SCHOOL #2FACILITY NUMBER:
570310219
ADMINISTRATOR:BECKY MONTGOMERYFACILITY TYPE:
850
ADDRESS:426 WEST EIGHTH STREETTELEPHONE:
(530) 757-5377
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 26DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Beck MontgomeryTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Salene Mayberry met with Director Becky Montgomery for an unannounced Case Management Inspection. LPA observed 26 children being cared for by 2 teachers and 7 parent volunteers.

The purpose of today’s inspection was to follow up regarding water sampling that indicated an Action Level Exceedance in a drinking fountain which was tested for lead on 10/01/2022. On 10/10/2022 the facility was notified that lead levels were in exceedance of 5 parts per billion (ppb). Since receiving the notification the facility has completely removed the drinking fountain and the pipes were capped off.

During today’s visit LPA verified the drinking fountain has been removed. LPA informed Director that Grant funding for testing and remediation is available and information can be found in 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 Director. LPA discussed and provided Appeal Rights to Director. LPA posted the Notice of Site Visit and Director 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: Salene Mayberry
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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 10/27/2022 10:16 AM - It Cannot Be Edited


Created By: Salene Mayberry On 10/27/2022 at 09:59 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: DAVIS PARENT NURSERY SCHOOL #2
FACILITY NUMBER: 570310219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited

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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The facility has completely removed the drinking fountain and the pipes are capped off. This was visually confirmed by LPA during the visit today.
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Lead test results received by Licensing on 10/21/2022, tested on 10/1/2022, showed an outlet in the facility had 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:Salene Mayberry
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
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