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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317944
Report Date: 09/03/2024
Date Signed: 09/03/2024 01:42:03 PM

Document Has Been Signed on 09/03/2024 01:42 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EDWARD KEMBLE PRESCHOOLFACILITY NUMBER:
340317944
ADMINISTRATOR/
DIRECTOR:		VINCENT, ROSELINEFACILITY TYPE:
850
ADDRESS:7495 29TH STREET, ROOM 25TELEPHONE:
(916) 399-5028
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 19DATE:
09/03/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Chao XiongTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On Tuesday, September 3rd 2024, Licensing Program Analyst (LPA) Christopher Bello met with Site Supervisor, Chao Xiong, to conduct an unannounced case management Lead Exceedance Inspection. The purpose of today's inspection was to create a plan of correction following a report of lead exceedance in facility outlet.

On 12/27/2022, the facility tested water sample for lead. One water outlet sampled indicated an Action Level Exceedance (ALE). The outlet that tested in exceedance is sink faucet D with 5.6ppb. Site Supervisor explained that she just started working at the facility this year and will inquire with Site Coordinator about the correction. The facility was notified that water lead levels were in exceedance of 5.5 parts per billion and that corrective actions are being taken.

A plan of correction is being issued to ensure the outlet is made inoperable, removed, and/or replaced. All other faucets used by preschool children have been tested and are not in Action Level Exceedance. Director will connect with the school district to decide to either cap off the tap or to replace and retest the outlet. LPA printed and provided LIC9275 and LIC9276 for Site Supervisor to complete and submit.

LPA informed Licensee Representative of Grant funding for testing and remediation is available referenced from Provider Information Notice (PIN) 21-04-CCP.

A deficiency is cited on the following LIC809-D page and the plan of correction was reviewed with the Site Supervisor, Chao Xiong. An exit interview was conducted with Site Supervisor, Chao Xiong. A copy of this report and appeal rights were also provided, as well as a notice of site visit which much remain posted for 30 consecutive days.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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 09/03/2024 01:42 PM - It Cannot Be Edited


Created By: Christopher Bello On 09/03/2024 at 12:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EDWARD KEMBLE PRESCHOOL
FACILITY NUMBER: 340317944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2024
Section Cited

101700.3(b)(1)

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California Lead Action Level at Child Care Centers (b) Testing results with ... (1) A ... values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement has not been met by evidence: Outlet D has a lead exceedance of 5.6ppb. This is considered as a potential
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Facility will provide proof of correction by POC date: 10/3/24.
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risk to the children 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:Amanda Blesi
LICENSING EVALUATOR NAME:Christopher Bello
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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