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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173003097
Report Date: 01/30/2023
Date Signed: 01/30/2023 11:55:49 AM

Document Has Been Signed on 01/30/2023 11:55 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:POMO EARLY CONNECTIONFACILITY NUMBER:
173003097
ADMINISTRATOR:HERNANDEZ, TERESAFACILITY TYPE:
850
ADDRESS:3350 ACACIA STREETTELEPHONE:
(707) 994-1960
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 17DATE:
01/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Teresa HerandezTIME COMPLETED:
12:10 PM
NARRATIVE
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On 01/30/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Site Supervisor, Teresa Herandez. The inspection was made in response to water lead testing results received from the facility. The test results showed that the following simples tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site B had a reading of 8.2 ppb. All other sources of water tested below the allowable level of 5.0 ppb. Prior to visit, Child Development Program Director, Megan Handy and Operations and Emergency Services Director, Robert Young notified LPA of the lead testing and as submitted the facility’s plan of correction 01/25/2023.

During today’s inspection, LPA observed the drinking fountain to be already shutoff and the faucet sprayer temporarily covered, making it inaccessible to children. The children in care are receiving drinking water from a water jug and cups. #### stated the water fountain has been turned off as of March 2020 due to COVID 19 and the facility plans to remove the water fountain/faucet sprayer from the premise.

On 01/24/2023, the facility has submitted the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to CCL.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Site Supervisor, Teresa Herandez

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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 01/30/2023 11:55 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 01/30/2023 at 10:53 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: POMO EARLY CONNECTION
FACILITY NUMBER: 173003097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited

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101700.3(b)(1) A result with values of 5.0 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
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Based on record review, facility drinking fountains/ ( Site “B”) exceeded the allowable levels of lead in the water, testing at 8.5 ppb. This is a potential health and safety risk to 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:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023


LIC809 (FAS) - (06/04)
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