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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185406614
Report Date: 08/30/2024
Date Signed: 08/30/2024 12:51:51 PM

Document Has Been Signed on 08/30/2024 12:51 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SUSANVILLE STATE PRESCHOOLFACILITY NUMBER:
185406614
ADMINISTRATOR/
DIRECTOR:		TOMSON, MARYFACILITY TYPE:
850
ADDRESS:2005 FOURTH STREETTELEPHONE:
(530) 257-9781
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:16 PM
MET WITH:Mary Thomson - Director TIME VISIT/
INSPECTION COMPLETED:
12:51 PM
NARRATIVE
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On 08/30/2024 at 12:16am, Licensing Program Analyst (LPA) Sydney Sims made a case management inspection and met with Mary Thomson . The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucets tested above the allowable level (5.5 ppb or greater) of lead in the water:

Faucet “E” – Back Kitchen Sink, 9.6ppb

The Director has made the faucet(s) inaccessible by creating sign that say "hand wash only" and the sinks are in a locked kitchen inaccessible to children .
The Director plans to replace and retest the faucet or turn off water source to faucet. The Director will inform LPA Sims by 9/13/24 if the faucet will be retested or shut off.

The following deficiency is being cited (see LIC 809D). A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the director Mary Thomson.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 12:51 PM - It Cannot Be Edited


Created By: Sydney Sims On 08/30/2024 at 12:37 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SUSANVILLE STATE PRESCHOOL
FACILITY NUMBER: 185406614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
HSC
101700.3(b)(2)

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101700.3(b)(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.
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The faucet is in an off limits area by baby gates and temporarily inaccessible by hand wash only and no food prep signs. The facility plans to either replace and retest the faucet or make faucet perminatley inaccesible. Director will update LPA Sims by 9/13/24
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This requirement was not met as evidenced by:
Based on record review, the facility had 1 faucet with lead test results exceeding 5 ppb of lead in the water. This is a potential health and safety risk to 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:Megan Aviles
LICENSING EVALUATOR NAME:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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