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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318372
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:28:20 AM

Document Has Been Signed on 01/13/2023 11:28 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:CORDOVA MEADOWS ELEMENTARY SCHOOLFACILITY NUMBER:
340318372
ADMINISTRATOR:YIM, JEANFACILITY TYPE:
850
ADDRESS:2550 LA LOMA DRIVETELEPHONE:
(916) 363-3818
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 21DATE:
01/13/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jacqueline WiseTIME COMPLETED:
11:40 AM
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On 01/13/2023 Licensing Program Analysts (LPAs) Arianna Manabat and Tiffanie Diep met with Facility Representative Jacqueline Wise for the purposes of an unnanounced case management inspection regarding lead testing. During time of arrival 21 children present with three staff members. Everyone subject to a criminal background clearance has obtained one. Facility Representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center.

On 11/30/2022, the facility tested water samples for lead. Results of the testing have indicated an Action Level Exceedance (ALE) of 21 UG/L for a water fixture (labeled sample #B in the testing). On 12/01/2022 the facility was notified that water levels were in exceedance of 5 parts per billion in the locations that were tested. The drinking fountain that was tested and identified is not utilized for any daily activities or drinking. LPA Manabat has observed a refrigerator that has an accessible water dispenser and is utilized by the facility instead of the tested fountain. Children are utilizing individual water bottles that are brought from home and refilled via the refrigerator water. The refrigerator water was tested/inspected by Lab services.

During interviews with Facility Representatives, LPA Manabat learned that the fixtures for the facility are not utilized for the purposes of drinking and that this particular faucet has been operable for two years. Facility Representative stated that they have notified authorized representatives of the lead exceedance, have been preemptive about flushing the faucet, and have made corrective actions by following up with California Laboratory services. LPAs informed present staff that Grant funding for testing and remediation is available referenced from Provider Information Notice (PIN) 21-04-CCP.A copy of this report was provided to the Facility Representative and appeal rights were assessed. Exit interview was conducted and report was reviewed with the Facility Representative. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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 01/13/2023 11:28 AM - It Cannot Be Edited


Created By: Arianna Manabat On 01/13/2023 at 11:11 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: CORDOVA MEADOWS ELEMENTARY SCHOOL
FACILITY NUMBER: 340318372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
101700.3(b)(1)

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101700.3 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 is not met as evidenced by:
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Drinking fountain is not in use and has never been utilized for children activites during time of operation. Facility has been assessed a POC cleared letter as of 01/13/23.
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Based on record review, one faucet tested exceeded the allowed 5.5 ppb, which poses/posed a potential 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:Roxana Saravia
LICENSING EVALUATOR NAME:Arianna Manabat
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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