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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310310244
Report Date: 01/24/2023
Date Signed: 01/24/2023 01:24:50 PM

Document Has Been Signed on 01/24/2023 01:24 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ADVENTURE CLUB - SARGENT ELM AFTER SCHOOL PROGRAMFACILITY NUMBER:
310310244
ADMINISTRATOR:RFACILITY TYPE:
840
ADDRESS:1200 RIDGECREST WAYTELEPHONE:
(916) 783-1908
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 9DATE:
01/24/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Monique MejoradoTIME COMPLETED:
01:40 PM
NARRATIVE
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On 01/24/2023, Licensing Program Analysts (LPAs) Jeremey McClain and Erwina Pascual-Golamco met with Licensing Representative Monique Mejorado for an unannounced Case Management Inspection. Upon arrival, LPAs observed 9 children supervised by two staff members.

On 12/09/2022, a sample from a faucet/fountain combo located in the classroom was collected and tested for lead exceedance. Results indicated lead values 6.9 parts per billion (pbb), exceeding the recommended 5.5 pbb. The source was previously used for drinking, washing hands, and cooking.

Usage of the water source was stopped immediately upon receiving the results, and the fountain and faucet has been made inaccessible. The facility will retest the source for lead exceedance once it has been replaced. Currently, children are bringing their own water bottles for drinking and there are other faucets that available for cooking and washing hands.

Deficiencies are cited on the subsequent page of the report and are considered a potential threat to the health and safety of children in care, if not corrected.

An exit interview was conducted with the Licensing Representative. The facility has posted the report indicating the results. LPA provided licensing representative with Appeal Rights, and a Notice of Site Visit that must be posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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 01/24/2023 01:24 PM - It Cannot Be Edited


Created By: Jeremey McClain On 01/24/2023 at 01:06 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: ADVENTURE CLUB - SARGENT ELM AFTER SCHOOL PROGRAM
FACILITY NUMBER: 310310244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2023
Section Cited

101700.3(b)(1)

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California Lead Action Level at Child Care Centers. b) Testing results with fractional ppb readings of 0.5 or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. 1) A result with calues of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not
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Usage of the water source was stopped immediately and the faucet and fountain were taped off. Children use their own water bottles for drinking and there are other faucets on site for washing hands and drinking. The facility will test the source at a later date once repairs/replacements have been made.
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met as evidenced by lead results of a faucet/fountain combo indicating a result of 6.9 pbb on 12/09/22. This is a potential risk to the healtha and safety of children in care if not corrected.
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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:Keven Peters
LICENSING EVALUATOR NAME:Jeremey McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023


LIC809 (FAS) - (06/04)
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