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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300156
Report Date: 10/03/2022
Date Signed: 10/03/2022 02:33:20 PM

Document Has Been Signed on 10/03/2022 02:33 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:CORDOVA BAPTIST PRESCHOOLFACILITY NUMBER:
340300156
ADMINISTRATOR:HUPPERT, CARRIEFACILITY TYPE:
850
ADDRESS:10527 COLOMA ROADTELEPHONE:
(916) 638-5506
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 87TOTAL ENROLLED CHILDREN: 87CENSUS: 14DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Carrie HuppertTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst Jennifer Velasco (LPA) met with Facility Representative Director Carrie Huppert (D1) for an unannounced Case Management Inspection. LPA observed 14 children in care with three staff. The purpose of today’s inspection was to follow up regarding water sampling that indicated Action Level Exceedance (ALE) for a water outlet that was tested for lead levels on 09/06/2022. D1 stated outlet A is the facility's kitchen sink and that the rest of the outlets have been covered and children bring water bottles and the facility uses bottled water. D1 stated that outlet A was rarely used before, and it will not be used at all now until the exceedance is remediated. LPA informed D1 that Grant funding for testing and remediation is available referenced from Provider Information Notice (PIN) 21-04-CCP.
Usage of the faucet for cooking was stopped immediately upon receiving the results, and bottled water is now being used a source for water. A new faucet will be ordered. The facility will retest the faucet for lead exceedance once it has been replaced.
On the following page of this report is citation of a deficiency that poses a potential threat to the health and safety of children in care if not corrected. LPA reviewed this report with the Facility Representative and conducted an exit interview. A Notice of Site Visit was provided and should remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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 10/03/2022 02:33 PM - It Cannot Be Edited


Created By: Jennifer Velasco On 10/03/2022 at 12:38 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: CORDOVA BAPTIST PRESCHOOL
FACILITY NUMBER: 340300156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2022
Section Cited

101.700.3(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 values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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Director immediately stopped usage of the kitchen sink faucet for cooking. Facility currently uses water from an Alhambra water station for cooking as needed. Facility has order a replacement faucet that will be retested for lead exceedance once replaced.
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 This requirement was not met as evidenced by results of a kitchen sink faucet on 9/6/22 that indicated the kitchen sink faucet was in exceedance of 5.5 ppb. This is a potential risk to the health and safety of children in care if not corrected.
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 Director will send results to LPA once the new faucet has been retested.

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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:Natalie Dunaway
LICENSING EVALUATOR NAME:Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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