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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343610141
Report Date: 02/07/2024
Date Signed: 02/07/2024 10:36:56 AM

Document Has Been Signed on 02/07/2024 10:36 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:KINGSWOOD ELEMENTARYFACILITY NUMBER:
343610141
ADMINISTRATOR:RONDONI, CHRISTINAFACILITY TYPE:
850
ADDRESS:5700 PRIMROSE DRIVETELEPHONE:
(916) 867-2046
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 36DATE:
02/07/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Christina RondoniTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Stephanie Piring and Soleil Marx met with Facility Representative, Christina Rondoni to conduct an unannounced case management inspection regarding lead testing. The purpose of today's inspection was to document a plan of correction following reports of lead exceedance in two of the facility outlets.

On 12/14/2023, the facility tested water samples for lead. Lead testing identified two water outlets that has a Lead Exceedance over the amount of 5.5 parts per billion (ppb). The water outlet designated as outlet E has an exceedance of 11 ppb, and outlet F has an exceedance of 29 ppb.



Facility Representative stated water outlets with lead exceedance were covered and placed out of order, the fixtures have been replaced and awaiting retesting. The facility is using an alternative water source, filtered water dispenser.


A deficiency is cited on the subsequent page of the report and is considered a potential threat to the health and safety of children in care. An exit interview was conducted with the Facility Representative. LPA provided Facility Representative with Appeal Rights and a Notice of Site Visit that must be posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Stephanie Piring
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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 02/07/2024 10:36 AM - It Cannot Be Edited


Created By: Stephanie Piring On 02/07/2024 at 09:53 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: KINGSWOOD ELEMENTARY
FACILITY NUMBER: 343610141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2024
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 is not met as evidenced by:
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Usage of the faucets was stopped immediately upon receiving the results. Facility Representative stated the faucets have been changed and awaiting retesting. Alternative filtered water dispenser is being used.
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Based on record review, two water outlets 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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Facility plan to flush water faucets and retest, Facility Representative will send updated passing results to LPA Piring prior to using the fixtures.

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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:Stephanie Piring
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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