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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617176
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:37:08 PM


Document Has Been Signed on 03/01/2023 03:37 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:SAINT JOHN THE EVANGELIST PRESCHOOLFACILITY NUMBER:
343617176
ADMINISTRATOR:CHAGOLLA, MARIAFACILITY TYPE:
850
ADDRESS:5701 LOCUST AVENUETELEPHONE:
(916) 481-8845
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:60CENSUS: 14DATE:
03/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria ChagollaTIME COMPLETED:
03:45 PM
NARRATIVE
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On March 1, 2023, at approximately 2:45 PM Licensing Program Analyst (LPA) Josiah Gathing met with Director Maria Chagolla to conduct an unannounced case management inspection. During today's inspection there were 14 preschool children being supervised by 2 teachers. The purpose of today's inspection was to create a plan of correction following a report of lead exceedance in one of the facility outlets.

On January 6, 2023, the facility tested water samples for lead. One water outlet sampled indicated an Action Level Exceedance (ALE). This outlet is marked B on the facility sketch provided by the center. Outlet B correlates to a sink located inside the office/staff room. On January 23, 2023 the facility was notified that water levels were in exceedance of 5 parts per billion in outlet B.

During today’s inspection, Director informed LPA that outlet B has never been used for food preparation or drinking water, and is only used for art supplies and cleaning. LPA observed art supplies in and around outlet B. Outlet B was tested in error. However, a plan of correction is being issued in accordance with lead exceedance guidelines. All faucets used for drinking and food preparation have been tested and are not in Action Level Exceedance. LPA received the lead testing map and other required documents from the Director during today's inspection.

A deficiency is cited on the following LIC809-D and the plan of correction was reviewed with the Director, Maria Chagolla. A copy of this report and appeal rights were provided to the Director.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
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 03:37 PM - 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: SAINT JOHN THE EVANGELIST PRESCHOOL
FACILITY NUMBER: 343617176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited

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101700.3 ...Lead Action Level... (b) ...(1) If testing indicates an Action Level Exceedance at any water outlet, the water... is deemed not safe to drink and an immediate response... shall be required.
This requirement was not met as evidenced by:
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This outlet is never used for drinking or food preparation and was tested in error.
Director was advised to contact lead testers to request removal of the exceedance from the database.
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Based on record review the facility did not comply with the above regulation as the lead action level was exceeded in one water outlet, which poses Health, Safety, or Personal Rights risk to persons 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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
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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