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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364801956
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:43:36 PM

Document Has Been Signed on 08/15/2023 01:43 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SBCSS ANNA BORBA STATE PRESCHOOLFACILITY NUMBER:
364801956
ADMINISTRATOR:JENELYN PEREZFACILITY TYPE:
850
ADDRESS:4980 RIVERSIDE DRIVETELEPHONE:
(909) 464-2695
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 24TOTAL ENROLLED CHILDREN: 19CENSUS: 9DATE:
08/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jenelyn PerezTIME COMPLETED:
02:00 PM
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On 08/15/2023, Licensing Program Analyst (LPA) Rachel Zeron conducted a case management inspection due to required lead testing requirements based on lead testing results received on the facility. LPA toured Preschool Room , took census and met with Jenelyn Perez, Site Supervisor to further discuss lead results received and measures taken for remediation of lead exceedances.


During the inspection, LPA toured and observed the following water outlets identified with lead exceedances: outlet A30 (tested at 8 ppb), B30 (tested at 7.5 ppb), A (tested at 6.5 ppb), B (tested at 6.2 ppb) were identified; Outlet A30 is a drinking fountain that is located in classroom 2 . Outlet B30 is a hand washing sink located in classroom 2. Outlet A is a drinking fountain that is located in the classroom. Outlet B is a hand washing sink that is located in the classroom . LPA verified that the required signage for cessation of use was in place at all outlets. Currently, classroom 2 is not in use.

Facility implemented the following plan of action until formal remediation can be completed on water outlets .The Director covered drink water outlets, posted required signage for non-use and will complete repairs to the outlets affected. Facility is in the process of repairs and retesting. LPA observed notification of lead results posted on the parent board.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SBCSS ANNA BORBA STATE PRESCHOOL
FACILITY NUMBER: 364801956
VISIT DATE: 08/15/2023
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Additionally, the following resources were discussed and provided from PIN 21-21-CCP dated July 28, 2021:

101700.6 Grant Funding for Qualifying Child care Centers

(a) Senate Bill 862, Chapter 449, Statutes of 2018 allocated $5 Million to the State Water Resources Control Board for testing and remediation of lead in the drinking water of Child Care Centers based on the following criteria:

(1) Those that serve children zero to five years of age, with the highest priority for Child Care Centers that provide care for children zero to three years of age.

(2) Those that have 50 percent or more of their registered children who receive subsidized care.

(3) Those that operate only one facility.

(b) To determine a Child Care Center’s eligibility for possible funding the Department will provide access to a link to an online eligibility form located on the Department’s website and on Sacramento State’s Office of Water Programs website.

(1) A Child Care Center interested in financial assistance shall complete the eligibility form, which shall include instructions for completing and returning it, prior to receiving any grant funding for which it may qualify. To determine a Child Care Center’s eligibility for possible funding, the provider will need to complete an online eligibility form available at Office of Water Programs’ website

No deficiencies cited.

An exit interview was conducted, LPA provided Jenelyn Perez, Site Supervisor, with a copy of this report, and notice of site visit. This report must be made available to the public upon request for three years

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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Document Has Been Signed on 08/15/2023 01:43 PM - It Cannot Be Edited


Created By: Rachel Zeron On 08/15/2023 at 01:33 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SBCSS ANNA BORBA STATE PRESCHOOL
FACILITY NUMBER: 364801956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
101700.3(b)(1)

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California Lead Action Level at Child Care Centers 101700.3 (b)(1): A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance

This requirement is not being met as evidenced by:
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 Site Supervisor agrees to have all repairs and retesting completed by POC date. The sink will be used by staff and children for hand washing only. Site supervisor will submit photos once repairs are complete.
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Based on records review of required lead testing, the facility had lead values of 5.5 ppb or above on water outlets: A 30(8 ppb) , B30 (7.5 ppb) A (6.5 ppd) and B (6.2 ppd). This is a potential health and safety 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:Aaron Ross
LICENSING EVALUATOR NAME:Rachel Zeron
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


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