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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030319700
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:49:25 AM

Document Has Been Signed on 08/22/2023 11:49 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PIONEER STATE PRESCHOOLFACILITY NUMBER:
030319700
ADMINISTRATOR:JESSICA VAUGHNFACILITY TYPE:
850
ADDRESS:24625 HIGHWAY 88TELEPHONE:
(209) 295-6503
CITY:PIONEERSTATE: CAZIP CODE:
95666
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 18DATE:
08/22/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Site Supervisor: Vaghn, Jessica TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Mariya Melnichuk met with Site Supervisor Jessica Vaughn for a Case Management inspection. The purpose of the inspection was to follow-up on a lead testing report dated 06/29/2023 which tested the water in the facility.

LPA was notified of the lead testing report which was dated 06/29/2023. The report revealed that three water outlets had elevated levels of lead. LPA was not provided a facility sketch to identify specific water outlets in the classroom. Site Supervisor stated that she will work with the director and the district office to identify the outlets affected.

As a result of the water testing positive for lead, a deficiency was cited on a subsequent page, 809D. An exit interview was conducted and the report was reviewed with Site Supervisor. A Notice of Site visit 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: Mariya Melnichuk
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 08/22/2023 11:49 AM - It Cannot Be Edited


Created By: Mariya Melnichuk On 08/22/2023 at 11:18 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PIONEER STATE PRESCHOOL
FACILITY NUMBER: 030319700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
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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Site Supervisor will work with director to identify affected water outlets, flush the water and retest.

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The water report dated 06/29/2023 revealed that the facility had elevated levels of lead in three outlets. 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:Mariya Melnichuk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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