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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 034501027
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:11:46 AM

Document Has Been Signed on 05/01/2024 11:11 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MOTHER LODE MOUNTAIN TOTS PRESCHOOLFACILITY NUMBER:
034501027
ADMINISTRATOR/
DIRECTOR:		ALLEN, KIRBIEFACILITY TYPE:
860
ADDRESS:23714 STATE HIGHWAY 88TELEPHONE:
(209) 457-0995
CITY:PIONEERSTATE: CAZIP CODE:
95666
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 20DATE:
05/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Director, Kirbie AllenTIME VISIT/
INSPECTION COMPLETED:
11:31 AM
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On May 1, 2024, Licensing Program Analysts (LPAs) Elizabeth Santiago and Carla Polanco met with Director Kirbie Allen for a Case Management inspection. The purpose of the inspection was to follow-up on a lead testing report dated 02/10/2024 received by CCLD.

LPA was notified of the lead testing report on 02/10/2024. The report revealed that one water outlet had elevated levels of lead. During today's inspection, LPA verified that the affected water outlet is not in use, and it was mistakenly tested as it is a staff bathroom. LPA verified that the faucet that was in exceedance was mistakenly tested because they are not used for drinking or food preparation. LPA and Director discussed the need to have the water testing report amended to reflect this, and to have the amended report resubmitted.

An exit interview was conducted, and the report was reviewed with Director. 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: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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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