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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340314894
Report Date: 02/23/2024
Date Signed: 02/23/2024 10:51:05 AM

Document Has Been Signed on 02/23/2024 10:51 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COYLE AVE HEAD START & STATE PRESCHOOLFACILITY NUMBER:
340314894
ADMINISTRATOR:GLASS, JESIKAFACILITY TYPE:
850
ADDRESS:6330 COYLE AVE.TELEPHONE:
(916) 979-8015
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
02/23/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brittney RandTIME COMPLETED:
11:05 AM
NARRATIVE
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On February 23, 2024, at approximately 10:30 AM Licensing Program Analyst (LPA) Josiah Gathing met with Program Secretary Brittney Rand to conduct an unannounced case management inspection. School was closed and there were no children in care during today's inspection. The purpose of today's inspection was to create a plan of correction following reports of lead exceedance in three of the facility outlets.

On December 14, 2023, the facility tested water samples for lead. One water outlet sampled indicated an Action Level Exceedance (ALE). This outlet is marked A on the facility sketch provided by the center. On January 22, 2024 the Licensing Program was notified that water levels were in exceedance of 5 parts per billion in tested location.

Signs have been placed on the outlet in exceedance stating that the outlet should not be used for drinking or food preparation. Program Secretary stated that the faucet has already been replaced, will be flushed daily once school session resumes, and will be re-tested in three weeks. LPA received the lead testing map and other required documents (LIC 9275 External Water Sampler Self-Certification Form and LIC 9276 Child Care Center Sampling Checklist Form) from Program Secretary during today's inspection.

A deficiency is cited on the following LIC809-D and the plan of correction was reviewed with Program Secretary, Brittney Rand. A copy of this report and appeal rights were provided to Program Secretary.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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 02/23/2024 10:51 AM - It Cannot Be Edited


Created By: Josiah Gathing On 02/23/2024 at 10:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COYLE AVE HEAD START & STATE PRESCHOOL
FACILITY NUMBER: 340314894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2024
Section Cited
HSC
101700.3(b)(1)

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101700.3 ...Lead Action Level... (b) ...(1) If testing indicates an Action Level Exceedance at any water outlet, the water... is deemed not safe to drink and an immediate response... shall be required. This requirement was not met as evidenced by:
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LPA confirmed during inspection that faucet tested in exceedance has already been replaced. Staff created a letter to notify parents what has been done remidiate the lead exceedance (e.g. sign, outlet replacement, and re-testing). Deficiency cleared during inspection.
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Based on record review the facility did not comply with the above regulation as the lead action level was exceeded in one water outlet, which poses 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:Seychelle De Luca
LICENSING EVALUATOR NAME:Josiah Gathing
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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