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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 223808272
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:52:38 AM

Document Has Been Signed on 11/17/2022 11:52 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:FIRST 5 MARIPOSA COUNTY BUILDING BLOCKS PRESCHOOLFACILITY NUMBER:
223808272
ADMINISTRATOR:HARPER, JEANINEFACILITY TYPE:
850
ADDRESS:2421 HIDALGOTELEPHONE:
(209) 852-9656
CITY:LA GRANGESTATE: CAZIP CODE:
95329
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jeanine HarperTIME COMPLETED:
12:00 PM
NARRATIVE
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On 11/17/22 Licensing Program Analysts (LPAs) Priscilla Zamudio and Araceli Gibson conducted an unannounced case management inspection. LPAs met with Jeanine Harper, Director 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 First 5 Mariposa County Building Blocks #223808272 impacted with an ALE of 5.6 ppb in outlet D (drinking fountain). These results indicate out of compliance over (ALE) 5.5 ppb. (See Plan of correction for further corrective action 809D). Outlet has temporarily been made inoperable and is in the planning stages of removal.

Director is providing water and cups to the preschool children by means of Alhambra water bottle service. Director agrees to have fresh potable water available to preschool children, visitors and staff during hours of operation. Parents have been notified of the (ALE ) Per PIN 20-20 CCP WD 101704 (b)(3). Facility also posted results in a reasonable location available for authorized representatives to review Per PIN 20-20 CCP WD 101703 (b).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, A type B deficiency is being cited: (see next page, 809 D). Director was provided a copy of appeal rights. An exit interview was conducted with the Director. 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: Priscilla Zamudio
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 11:52 AM - It Cannot Be Edited


Created By: Priscilla Zamudio On 11/17/2022 at 11:23 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: FIRST 5 MARIPOSA COUNTY BUILDING BLOCKS PRESCHOOL
FACILITY NUMBER: 223808272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
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. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. (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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Director has notified and posted ALE results at a reasonable location for Authorized representatives to review. Director agrees to provide evidence of the removal of outlet D by 12/15/2022.
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This requirement was not met based on record review provided by Director indicating ALE of 5.6 ppb in outlet D (drinking fountain). These results indicate out of compliance over (ALE) 5.5 ppb. 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:Priscilla Zamudio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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