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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100407357
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:42:19 PM

Document Has Been Signed on 01/12/2023 01:42 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:CHILD DEVELOPMENT-STATE PRESCHOOL-SIERRA VISTAFACILITY NUMBER:
100407357
ADMINISTRATOR:LOGAN, TARAFACILITY TYPE:
850
ADDRESS:510 BARSTOWTELEPHONE:
(559) 327-7986
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
01/12/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Bonita Gomez - TeacherTIME COMPLETED:
02:00 PM
NARRATIVE
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On 1/12/23 Licensing Program Analyst (LPA) Joseph Pacheco conducted an unannounced case management inspection. LPA met with Teacher, Bonita Gomez for the purpose of conducting a case management inspection, regarding a lead exceedance referred to as an Action Level Exceedance (ALE) of over 5.5 parts per billion (ppb) in the water at the facility.

Fresno Regional Office received notification of water lead exceedance at the facility resulting from a recent water lead sampling test. Based on records reviewed from the Environmental Laboratory Accreditation Program (ELAP) report and self-reported information for CUSD – Sierra Vista License # 100407357 impacted with an ALE of 5.94 ppb in Outlet C Preschool Bubbler. These results indicate out of compliance over (ALE) 5.5 ppb. During today’s inspection LPA observed that Outlet C Preschool Bubbler has been removed. LPA observed facility is providing alternative potable water via Valley Springs Water Service to children, visitors, and staff during hours of operation. LPA also observed alternative water fountains.

Teacher stated children’s authorized representatives have been notified of the ALE Per PIN 21-21.1 CCP WD 101704(b)(3). Facility has also posted results for parents to review Per PIN 21-21.1 CCP WD 101703(b).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D). Teacher, Bonita Gomez was provided a copy of appeal rights. An exit interview was conducted. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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 01/12/2023 01:42 PM - It Cannot Be Edited


Created By: Joseph Pacheco On 01/12/2023 at 01:24 PM
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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: CHILD DEVELOPMENT-STATE PRESCHOOL-SIERRA VISTA
FACILITY NUMBER: 100407357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2023
Section Cited

101700.3

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California Lead Action Level at Child Care Centers (a) California’s Action Level for lead in water at Child Care Centers is 5 ppb. (b) Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. Testing results with fractional ppb readings of less than 0.5 ppb shall be rounded down to the nearest whole number, before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. (2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. (c) If testing indicates an Action Level Exceedance at any water outlet, the water from that outlet is deemed not safe to drink and an immediate response pursuant to section 101704 shall be required.
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Outlet C Preschool Bubbler was removed and the line was permanently capped ceasing use on 12/5/22. Authorized representatives were notified on 12/5/22 and the report has been posted on the parent board in the classroom. Deficiency cleared.
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This requirement was not met as evidenced by based on record review provided by Licensee indicating ALE of 5.94 ppb in Outlet C Preschool Bubbler. These results indicate an exceedance over ALE 5.5 ppb, which is out of compliance. This poses a 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:Diana deLeon
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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