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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312840
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:04:32 AM

Document Has Been Signed on 01/17/2023 11:04 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:4TH R - SEQUOIAFACILITY NUMBER:
340312840
ADMINISTRATOR:MICHELE CARTHENFACILITY TYPE:
840
ADDRESS:3333 ROSEMONT DRIVETELEPHONE:
(916) 277-6105
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 100TOTAL ENROLLED CHILDREN: 100CENSUS: DATE:
01/17/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shelly CarthenTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Gagandeep Singh met with Program coordinator, Shelly Carthen, for a case management inspection. Purpose of the inspection was explained.

The facility had the water test conducted on December 07, 2022 for the lead. Based on the report, one of the faucet had the 08 PPB lead in the water. LPA dicussed with program coordinator that the Department's requirements are that the findings must be lower than 5.5 PPB. During the inspection, LPA observed the faucet that has been tested with exceedance. Program Coordinator stated that the facility is not using that faucet for drinking. The facility is using the water dispenser with filter for drinking water.

Copy of this report was reviewed and provided to the Program Director. See next page for written directive provided today. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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 01/17/2023 11:04 AM - It Cannot Be Edited


Created By: Gagandeep Singh On 01/17/2023 at 09:41 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: 4TH R - SEQUOIA
FACILITY NUMBER: 340312840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
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 values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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During the inspection, Program Coordinator informed that the facility is not using the specific faucet for drinking water. LPA observed the facility is using water dispenser with the filter for drinking water.
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This requirement is not met as evidenced by: Based on results of a test conduct on a faucet on December 07, 2022 indicated 08 ppb in the faucet water, which exceed 5.5 ppb requirement. This is a potential risk to the health 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:Natalie Dunaway
LICENSING EVALUATOR NAME:Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


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