<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173003503
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:46:18 PM


Document Has Been Signed on 01/30/2023 01:46 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MIDDLETOWN EARLY CONNECTIONFACILITY NUMBER:
173003503
ADMINISTRATOR:PERRY, LIBERTYFACILITY TYPE:
850
ADDRESS:15846 WARDLAW STREETTELEPHONE:
(707) 987-9749
CITY:MIDDLETOWNSTATE: CAZIP CODE:
95461
CAPACITY:30CENSUS: 0DATE:
01/30/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Director, Megan Handy & Site Supervisor, Dawn McAuleyTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/30/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Child Development Program Director, Megan Handy & Site Supervisor, Dawn McAuley. 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 D had a reading of 18 ppb. All other sources of water tested below the allowable level of 5.0 ppb. Prior to visit, Director, Megan Handy and Operations and Emergency Services Director, Robert Young notified LPA of the lead testing and has submitted the facility’s plan of correction on 01/25/2023.

During today’s inspection, LPA observed the outside drinking fountain to be already shutoff and was removed from the premise. Director stated the water fountain has been turned off as of March 2020 due to COVID 19 and the water fountain was removed on 01/24/2023. The children in care are receiving drinking water from a filtered water jug and have individual cups.

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, Dawn McAuley.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
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)
Page: 1 of 2


Document Has Been Signed on 01/30/2023 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MIDDLETOWN EARLY CONNECTION
FACILITY NUMBER: 173003503

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

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
LPA observed the outside drinking fountain to be already shutoff and was removed from the premise. The facility has competed their plan of correction.
8
9
10
11
12
13
14
Based on record review, facility drinking fountains (Site “D”) exceeded the allowable levels of lead in the water, testing at 18 ppb. This is a potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
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)
Page: 2 of 2