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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 034501027
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:25:26 AM

Document Has Been Signed on 07/31/2024 11:25 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: 29DATE:
07/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Facility Representative, Naila HertzogTIME VISIT/
INSPECTION COMPLETED:
11:48 AM
NARRATIVE
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On July 31, 2024, Licensing Program Analyst Elizabeth Santiago (LPA) met with Facility Representative Naila Hertzog 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 disclosed the purpose of the inspection and was granted entrance into the Facility. LPA toured the facility and observed 29 children supervised by 3 staff members.

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 observed and 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 facility representative discussed and understands the need to have the water testing report amended to reflect this, and to have the amended report resubmitted to the Regional Office to remain in compliance.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). This facility has COMPLETED TESTING AND IS IN THE PROCESS OF REMEDIATING LEAD EXCEEDANCES

Report Continues on 809-C...

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 07/31/2024 11:25 AM - It Cannot Be Edited


Created By: Elizabeth Santiago On 07/31/2024 at 10:33 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: MOTHER LODE MOUNTAIN TOTS PRESCHOOL
FACILITY NUMBER: 034501027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/02/2024
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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During today's visit, LPA observed that the
affected water outlet is not in use. Licensee will schedule the water report to be amended to reflect faucet not in use and sent to the RO.
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Based on record review, the licensee did not comply with the section cited above in exceedance levels of lead on testing report which poses an potential 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:Chayntel Hunter
LICENSING EVALUATOR NAME:Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PRESCHOOL
FACILITY NUMBER: 034501027
VISIT DATE: 07/31/2024
NARRATIVE
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This is an amendment of a report done on 08/12/2024.

LPA received an amended report that water outlet was tested incorrectly.

An exit interview was conducted, and the report was reviewed with facility representative. 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: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
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